Nursing Elites

1. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best client position for the administration of bolus tube feedings?

• A. Prone.
• B. Fowler's.
• C. Sims'.
• D. Supine.

Correct answer: B

Rationale: The correct answer is Fowler's position. Placing the client in Fowler's position, with the head of the bed elevated to 45-60 degrees, reduces the risk of aspiration during bolus enteral feedings by facilitating the flow of the feeding into the stomach. Prone position (choice A) is lying face down, which is not suitable for feeding. Sims' position (choice C) is a side-lying position used for rectal examinations or enemas, not for feeding. Supine position (choice D) is lying flat on the back and is not optimal for reducing the risk of aspiration during bolus tube feedings.

2. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

• A. Liver damage
• B. Renal failure
• C. Gastric bleeding
• D. Heart attack

Correct answer: A

Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.

3. When demonstrating an empathic presence to a client, which of the following actions should the nurse take?

• A. Use an open posture
• B. Write down what the client says for accurate documentation
• C. Establish and maintain eye contact
• D. Nod in agreement with the client throughout the conversation

Correct answer: A

Rationale: Using an open posture is crucial when demonstrating empathy to a client. This body language conveys openness, understanding, and a willingness to listen, creating a safe space for the client to express themselves. Establishing and maintaining eye contact is also important as it fosters a sense of connection and validation for the client. Writing down what the client says is essential for accurate documentation and memory but does not directly contribute to demonstrating empathic presence. Nodding in agreement with the client throughout the conversation may show attentiveness, but it does not necessarily reflect empathy or active listening as it could be misinterpreted as simply agreeing with what is being said.

4. A client with diabetes mellitus is learning to self-administer insulin. Which action by the client indicates the need for further teaching?

• A. The client rotates injection sites on the abdomen.
• B. The client draws up the insulin dose after warming the vial to room temperature.
• C. The client pinches the skin before injecting the insulin.
• D. The client injects the insulin at a 90-degree angle.

Correct answer: B

Rationale: Drawing up insulin after warming the vial to room temperature indicates a need for further teaching, as insulin should be at room temperature for administration. Choice A is correct as rotating injection sites helps prevent lipodystrophy. Choice C is correct as pinching the skin helps ensure proper subcutaneous injection. Choice D is correct as injecting insulin at a 90-degree angle is the recommended technique for subcutaneous injections.

5. A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?

• A. Ask the client to state their full name.
• B. Ask the client for their date of birth.
• C. Compare the client's wristband with the medication administration record.
• D. Ask the client for their room number.

Correct answer: C

Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.

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