Nursing Elites

1. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

2. What is the initial intervention for a patient with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

3. A healthcare provider is reviewing laboratory results for a client who has diabetes mellitus. Which of the following tests is an indicator of long-term blood glucose control?

• A. Fasting blood glucose
• B. Glycosylated hemoglobin (HbA1c)
• C. Random blood glucose
• D. Postprandial blood glucose

Correct answer: B

Rationale: The correct answer is B, Glycosylated hemoglobin (HbA1c). HbA1c provides a measure of long-term blood glucose control over the past 2-3 months. This test reflects the average blood glucose levels during this period, making it a valuable tool in managing diabetes. Choices A, C, and D are not indicators of long-term blood glucose control. Fasting blood glucose measures the current glucose level after a period of not eating, random blood glucose provides a snapshot of the current glucose level, and postprandial blood glucose measures the glucose level after a meal.

4. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 95%
• B. Blood pressure of 130/85 mm Hg
• C. Coughing up small amounts of sputum
• D. Absent gag reflex

Correct answer: D

Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.

5. Which electrolyte imbalance is a common concern for patients on loop diuretics?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A, Hypokalemia. Loop diuretics can lead to potassium loss, resulting in hypokalemia. This imbalance is a common concern because potassium plays a vital role in various physiological functions, including maintaining proper heart function. Choices B, C, and D are incorrect because loop diuretics typically do not cause hyperkalemia, hyponatremia, or hypercalcemia.

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