Nursing Elites

1. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

• A. The family member washes out the feeding bag with warm water once every 24 hours.
• B. The family member washes out the feeding bag with hot water once every 24 hours.
• C. The family member washes out the feeding bag with soap and water every 24 hours.
• D. The family member changes the feeding bag every 24 hours.

Correct answer: A

Rationale: The correct answer is A. Washing out the feeding bag with warm water once every 24 hours is not sufficient to prevent bacterial growth and can lead to diarrhea. Using hot water may damage the feeding bag. Washing out the feeding bag with soap and water every 24 hours is excessive and may leave residue that could be harmful. Changing the feeding bag every 24 hours is important for preventing infections but does not directly address the issue of diarrhea in this case.

2. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by elevated body temperature, which can lead to hypotension (low blood pressure) due to dehydration and vasodilation. Bradycardia (slow heart rate) and clammy skin are not typical findings in heat stroke. Bradypnea (slow breathing) is also not a common feature of heat stroke. Therefore, hypotension is the most likely cardiovascular manifestation seen in a client with heat stroke.

3. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since timed-release capsules are not available at the time of discharge, which dosing schedule should the LPN advise the client to follow?

• A. 9 a.m., 1 p.m., and 5 p.m.
• B. 8 a.m., 4 p.m., and midnight.
• C. Before breakfast, before lunch, and before dinner.
• D. With breakfast, with lunch, and with dinner.

Correct answer: B

Rationale: The correct dosing schedule for the client to follow is to take the medication at 8 a.m., 4 p.m., and midnight. This timing spaces the doses evenly over the waking hours, ensuring consistent therapeutic levels of the medication. Choice A (9 a.m., 1 p.m., and 5 p.m.) does not evenly distribute the doses throughout the day. Choices C (Before breakfast, before lunch, and before dinner) and D (With breakfast, with lunch, and with dinner) do not provide the required frequency of dosing needed for optimal therapeutic effect.

4. During a Weber test, what is an appropriate action for the nurse to take?

• A. Deliver a series of high-pitched sounds at random intervals.
• B. Place an activated tuning fork in the middle of the client's forehead.
• C. Hold an activated tuning fork against the client's mastoid process.
• D. Whisper a series of words softly into one ear.

Correct answer: B

Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.

5. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

Similar Questions