Nursing Elites

1. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?

• A. Irrigate the tube with normal saline every shift.
• B. Check the tube placement by auscultation.
• C. Secure the tube to the client's gown.
• D. Flush the tube with 5 mL of sterile water before and after medication administration.

Correct answer: A

Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.

2. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?

• A. A client who has nasogastric suctioning
• B. A client who has chronic constipation
• C. A client who has syndrome of inappropriate antidiuretic hormone
• D. A client who took a toxic dose of sodium bicarbonate antacids

Correct answer: A

Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.

3. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
• B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

4. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

• A. Troponin level of 0.5 ng/mL
• B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
• C. Serum potassium of 4.5 mEq/L
• D. Blood glucose of 180 mg/dL

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

5. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

Similar Questions