Nursing Elites

1. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the nurse take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: To maintain the patency of a nasogastric (NG) tube, it is essential to flush the tube with 30 ml of water before and after medication administration. This action helps ensure that the tube remains open and free from blockages. Flushing the tube prevents any medication residue from causing blockages, maintaining its patency. Choice B is incorrect because administering medication with food does not relate to maintaining tube patency. Choice C is incorrect as verifying tube placement by aspirating stomach contents is related to confirming correct tube placement, not maintaining patency. Choice D is also incorrect because diluting the medication with normal saline is not primarily aimed at maintaining the tube's patency.

2. A client has undergone an allogeneic stem cell transplant, and a nurse is initiating a protective environment. Which precaution should the nurse plan for this client?

• A. Ensure the client wears a mask when outside the room if there is construction in the area.
• B. Place the client in a room with other immunocompromised patients.
• C. Allow the client to visit public areas freely.
• D. Ensure the client does not need any special precautions.

Correct answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to maintain a protective environment to prevent infections. Wearing a mask when outside the room, especially if there is construction in the area, helps reduce the risk of exposure to harmful pathogens. This precaution is essential as the client's immune system is compromised post-transplant. Placing the client in a room with other immunocompromised patients (choice B) would increase the risk of infections as it exposes the client to a higher pathogen load. Allowing the client to visit public areas freely (choice C) is not recommended due to the higher risk of exposure to infections. Ensuring the client does not need any special precautions (choice D) is incorrect because clients post allogeneic stem cell transplant require protective measures to prevent complications.

3. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

• A. Our child had chickenpox 6 months ago.
• B. Strep throat went through all the children at the day care last month.
• C. Both ears were infected over 3 months ago.
• D. Last week both feet had a fungal skin infection.

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

4. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?

• A. Lock the wheels on both the bed and stretcher
• B. Adjust the bed to a low position
• C. Ask the client to assist in the transfer
• D. Use a transfer sheet without locking the wheels

Correct answer: A

Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.

5. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:

• A. Is unable to swallow foods by mouth
• B. Has a gastrointestinal obstruction
• C. Requires additional caloric intake to support healing
• D. Is at risk for aspiration

Correct answer: A

Rationale: The correct answer is A: 'Is unable to swallow foods by mouth.' Tube feeding is prescribed when a client is unable to safely swallow food by mouth but has a functional gastrointestinal tract. Option B, 'Has a gastrointestinal obstruction,' is incorrect as tube feeding is not typically prescribed for this reason. Option C, 'Requires additional caloric intake to support healing,' is incorrect because tube feeding is specifically for clients who are unable to swallow. Option D, 'Is at risk for aspiration,' is also incorrect as tube feeding would not be the primary intervention for aspiration risk; other strategies to reduce aspiration risk would be implemented instead.

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