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. Which electrolyte imbalance is a potential side effect of diuretics?

• A. Hyperkalemia
• B. Hypercalcemia
• C. Hypomagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Diuretics commonly lead to hypokalemia, which is low potassium levels in the body. Hyperkalemia (choice A) is the opposite, indicating high potassium levels. Hypercalcemia (choice B) refers to elevated calcium levels, not typically associated with diuretics. Hypomagnesemia (choice C) is low magnesium levels and can also be a consequence of diuretic use, but potassium imbalance is more common.

3. The nurse is planning to provide education about foods containing thiamine to a group of clients. Which food high in thiamine should the nurse include?

• A. Fish
• B. Pork
• C. Beef
• D. Eggs

Correct answer: B

Rationale: The correct answer is B: Pork. Pork is high in thiamine, which is important for preventing thiamine deficiency. Thiamine, also known as Vitamin B1, is essential for the body's metabolism and proper functioning of the nervous system. While fish, beef, and eggs are nutritious foods, they do not contain as high levels of thiamine as pork does. Therefore, when educating clients about thiamine-rich foods, pork would be the most appropriate choice.

4. During the admission interview, which question should the nurse ask the male client diagnosed with aorto-iliac disease?

• A. “Do you have trouble sitting for long periods of time?”
• B. “How often do you have a bowel movement and urinate?”
• C. “When you lie down do you feel throbbing in your abdomen?”
• D. “Have you experienced any problems having sexual intercourse?”

Correct answer: D

Rationale: The correct answer is D: “Have you experienced any problems having sexual intercourse?” Aorto-iliac disease can lead to impaired blood flow to the pelvis and lower extremities, potentially causing sexual dysfunction. The other choices (A, B, and C) are less relevant to the specific effects of aorto-iliac disease on the client's health. While choice A may relate to discomfort, it does not directly address the impact of the disease on sexual function. Choices B and C are more general and do not specifically target the potential issues related to aorto-iliac disease.

5. The nurse is caring for the client one day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.

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