Nursing Elites

1. A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should avoid foods that contain lactose.
• B. You should increase your intake of high-fiber foods.
• C. You should avoid foods that contain gluten.
• D. You should increase your intake of dairy products.

Correct answer: A

Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.

2. A client with a new diagnosis of hyperlipidemia is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my intake of fiber.
• B. I will increase my intake of red meat.
• C. I will decrease my intake of saturated fats.
• D. I will increase my intake of salt.

Correct answer: C

Rationale: The correct answer is C. Decreasing saturated fats is essential in managing hyperlipidemia. Saturated fats can raise LDL cholesterol levels, contributing to the condition. By reducing intake of saturated fats, the client can help lower their cholesterol levels and improve their overall lipid profile. Choices A, B, and D are incorrect. Decreasing fiber intake (Choice A) is not recommended as fiber can help lower cholesterol levels. Increasing red meat intake (Choice B) is not advisable as red meat is often high in saturated fats. Increasing salt intake (Choice D) is unrelated to managing hyperlipidemia and can even be detrimental due to its association with high blood pressure.

3. What is a true statement about caring for a client with a nasogastric (NG) tube?

• A. The NG tube should be flushed with 30 mL of water every 4 hours.
• B. The client should be positioned in a supine position.
• C. The NG tube should be advanced 5 cm if resistance is met.
• D. The client's nasal mucosa should be inspected daily.

Correct answer: A

Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.

4. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

5. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?

• A. Inspection, percussion, palpation, auscultation
• B. Percussion, auscultation, inspection, palpation
• C. Auscultation, palpation, inspection, percussion
• D. Inspection, auscultation, percussion, palpation

Correct answer: D

Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.

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