Nursing Elites

1. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nursing assistant aspirates and measures the amount of the gastric aspirate
• B. The nursing assistant elevates the head of the client’s bed 30 degrees
• C. The nursing assistant warms the formula to room temperature
• D. B, C

Correct answer: D

Rationale: Elevating the head of the bed to 30 degrees reduces the risk of aspiration by promoting proper digestion and preventing reflux. Warming the formula to room temperature is essential to prevent discomfort and complications. Aspirating and measuring the gastric aspirate is not a recommended nursing action for monitoring enteral feeding via a nasogastric tube, as it can introduce the risk of introducing contaminants into the feeding tube. Therefore, choices A and B are incorrect, making choice D the correct answer.

2. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

• A. Instruct the client to avoid drinking fluids with meals
• B. Explain the need to decrease intake of flatus-forming foods
• C. Teach the client how to perform gentle perianal care
• D. Encourage the client to see a psychologist

Correct answer: B

Rationale: Choosing option B, explaining the need to decrease intake of flatus-forming foods, is the correct intervention to reduce IBS symptoms. Flatus-forming foods can worsen bloating and discomfort in individuals with IBS. Option A, instructing the client to avoid drinking fluids with meals, may be helpful for other conditions but is not a primary intervention for IBS. Option C, teaching perianal care, is not directly related to reducing IBS symptoms. Option D, encouraging the client to see a psychologist, may be beneficial for managing stress related to IBS but is not the initial intervention to reduce symptoms.

3. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?

• A. Collect early in the morning, First voided specimen
• B. Do perineal care before specimen collection
• C. Collect 5 to 10 ml for urine
• D. Discard the first flow of the urine

Correct answer: A

Rationale: When collecting a mid-stream clean catch urine specimen for urine analysis, it is important to collect an adequate amount of urine for accurate testing. A volume of 30 to 60 ml is usually recommended for optimal results, so collecting only 5 to 10 ml would not provide enough urine for testing purposes. It is essential to follow proper collection techniques to ensure accurate and reliable test results.

4. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

• A. Obtain a court order for the surgery
• B. Sign the informed consent on behalf of the client
• C. Send the client to surgery without the consent form being signed
• D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member, with the consent being witnessed by two healthcare providers, is the best course of action. This ensures that the client's best interests are considered and that proper authorization is obtained. Option A, obtaining a court order, is not necessary in this scenario and could delay the surgery. Option B, signing the consent on behalf of the client, is not appropriate as it may raise ethical and legal concerns. Option C, sending the client to surgery without a signed consent form, is not advisable as it violates the principles of informed consent and places the client at risk.

5. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?

• A. 32-year-old with diarrhea for 6 hours
• B. 2-year-old with 1 wet diaper in 24 hours
• C. 40-year-old with abdominal cramping
• D. 10-year-old who is nauseated

Correct answer: B

Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.

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