Nursing Elites

1. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?

• A. Elevate the head of the bed to 15 degrees during feedings
• B. Aspirate gastric contents before administering medications
• C. Clamp the tube between feedings
• D. Flush the tube with water before and after feedings

Correct answer: D

Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.

2. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?

• A. Localized warmth
• B. Calf pain
• C. Swelling in the affected leg
• D. Hematuria

Correct answer: D

Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.

3. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?

• A. I am sorry. Referral information can only be provided by the client's health care providers.
• B. I can never give any information out by telephone. How do I know who you are?
• C. Since this is a referral, I can give you this information.
• D. I need to get the client's written consent before I release any information to you.

Correct answer: D

Rationale: The correct answer is D: "I need to get the client's written consent before I release any information to you." In this scenario, the nurse must obtain the client's written consent before disclosing any information to the social worker. This process ensures compliance with privacy laws like HIPAA, which are designed to protect client confidentiality. Choice A is incorrect because it does not address the need for consent. Choice B is incorrect as it is unprofessional and does not focus on obtaining consent. Choice C is incorrect as it suggests information can be shared without consent, which goes against privacy laws.

4. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?

• A. Improved tolerance to cold.
• B. Decreased fatigue and improved energy levels.
• C. Reduced anxiety and improved mood.
• D. Increased sensitivity to heat.

Correct answer: B

Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.

5. A male client with a history of deep vein thrombosis (DVT) is admitted with new onset shortness of breath and a productive cough. What is the nurse's priority action?

• A. Administer prescribed anticoagulant.
• B. Notify the healthcare provider.
• C. Auscultate lung sounds.
• D. Prepare for chest physiotherapy.

Correct answer: A

Rationale: Administering an anticoagulant is the nurse's priority action in this situation. Given the client's history of DVT and the presentation of new onset shortness of breath and a productive cough, there is a concern for a pulmonary embolism, which is a life-threatening complication of DVT. Administering an anticoagulant promptly is crucial to prevent further clot formation and to manage the existing clot, reducing the risk of pulmonary embolism. While auscultating lung sounds and preparing for chest physiotherapy are important actions in respiratory assessment and management, the priority in this case is to address the potential complication of a pulmonary embolism by administering the anticoagulant. Notifying the healthcare provider can be done after initiating the immediate intervention of anticoagulant therapy.

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