Nursing Elites

1. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

2. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

3. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and tell you that the client from the other room was in Pain. The best intervention in such case is:

• A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the
• B. Tell the nursing assistant to give the pain medication to the client complaining of pain
• C. Tell the nursing assistant to go the client’s room and tell the client to wait
• D. Finish the bed bath quickly then rush to the client in Pain

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. What outcome has been shown to be a benefit of breastfeeding that directly impacts the mother?

• A. conserving calcium stores
• B. contracting the uterus
• C. protecting against future hypertension
• D. speeding the resumption of ovulation

Correct answer: B

Rationale: The correct answer is B, contracting the uterus. Breastfeeding helps contract the uterus after childbirth, reducing postpartum bleeding and helping the uterus return to its pre-pregnancy size more quickly. Choices A, C, and D are incorrect because conserving calcium stores, protecting against future hypertension, and speeding the resumption of ovulation are not direct benefits of breastfeeding to the mother.

5. A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

• A. Increased vital capacity
• B. Dry skin
• C. Heat intolerance
• D. Decreased mental status

Correct answer: D

Rationale: Malnutrition can lead to a variety of physical and mental symptoms. One common manifestation of malnutrition is a decreased mental status, which includes confusion, lethargy, and cognitive impairment. Dry skin is a typical finding in malnutrition due to the lack of essential nutrients needed for skin health. Heat intolerance is not a direct consequence of malnutrition. While malnutrition can affect respiratory function, it typically leads to decreased vital capacity rather than increased. Therefore, the correct answer is decreased mental status.

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