Nursing Elites

1. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

• A. Urinary incontinence
• B. Constipation
• C. Nystagmus
• D. Occult bleeding

Correct answer: D

Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.

2. The health care provider order reads 'aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?

• A. Hold the tube feeding and notify the provider
• B. Administer the tube feeding as scheduled
• C. Irrigate the tube with diet cola soda
• D. Apply intermittent suction to the feeding tube

Correct answer: A

Rationale: A pH of 10 indicates improper placement of the NG tube, requiring notification of the provider and holding the feeding. Choice B is incorrect because administering the tube feeding could lead to complications due to the improper placement. Choice C is incorrect as irrigating the tube with diet cola soda is not a standard practice for addressing this issue. Choice D is incorrect as applying intermittent suction does not address the problem of improper placement indicated by the high pH level.

3. Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?

• A. Assessing the client's level of consciousness
• B. Monitoring the client's oxygen saturation
• C. Checking the client's gag reflex before eating or drinking
• D. Monitoring the client's intake and output

Correct answer: C

Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.

4. A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?

• A. Figs
• B. Broccoli
• C. Stewed tomatoes
• D. Skim milk

Correct answer: D

Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.

5. A healthcare professional assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

• A. Flaccid paralysis
• B. Pupils fixed and dilated
• C. Diminished spinal reflexes
• D. Reduced sensory responses

Correct answer: B

Rationale: The correct answer is B: Pupils fixed and dilated. Fixed and dilated pupils are a critical neurological sign that indicates severe neurological damage or brain herniation, posing a significant concern for the patient's condition. Flaccid paralysis (choice A) typically indicates lower motor neuron injury, while diminished spinal reflexes (choice C) and reduced sensory responses (choice D) may suggest various neurological issues but are not as acutely concerning as fixed and dilated pupils in this scenario.

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