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 client newly diagnosed with type 1 diabetes mellitus is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statement?

• A. Insulin injections are not difficult to learn.
• B. Tell me what I can do to help you overcome your fear of giving yourself injections.
• C. It’s important to learn self-care for future independence.
• D. You need to learn this for your health.

Correct answer: B

Rationale: Choice B is the correct answer because it addresses the client's fear and offers support to help them overcome the resistance to self-care. By expressing willingness to assist and asking for ways to help the client, the nurse encourages open communication and collaboration in finding solutions to the client's concerns. Choices A, C, and D, while valid statements, do not directly address the client's fear or resistance, which is crucial in promoting self-care adherence in this situation.

3. The client with diabetes is being educated by the nurse on foot care. Which statement by the client indicates a need for further teaching?

• A. I will check my feet daily for any cuts or sores.
• B. I will avoid walking barefoot.
• C. I will soak my feet in warm water every day.
• D. I will wear shoes that fit well to avoid blisters.

Correct answer: C

Rationale: The correct answer is C. Soaking the feet in warm water daily is not recommended for clients with diabetes as it can cause the skin to become too soft, increasing the risk of skin breakdown and infections. Checking the feet daily for cuts or sores (A) is a good practice to prevent complications. Avoiding walking barefoot (B) helps protect the feet from injuries. Wearing well-fitted shoes (D) is essential to prevent blisters and other foot problems in diabetic clients. Therefore, the client's statement about soaking the feet in warm water daily indicates a need for further teaching.

4. What is the most important action for the nurse to take to prevent infection in a client who has just returned from surgery with an indwelling urinary catheter in place?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.

5. When providing oral care for an unconscious client, which of the following actions should the nurse take?

• A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
• B. Insert a suction catheter before brushing the teeth.
• C. Use a soft-bristled toothbrush only with water.
• D. Brush the client's teeth while they are in a supine position.

Correct answer: A

Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.

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