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. What intervention should the nurse implement for the client who has an ileal conduit?

• A. Pouch the stoma with a one-inch margin around the stoma
• B. Refer the client to the United Ostomy Association for discharge teaching
• C. Report to the healthcare provider any decrease in urinary output
• D. Monitor the stoma for signs and symptoms of infection every shift

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report any decrease in urinary output to the healthcare provider. Decreased urinary output in these clients may indicate a blockage or another complication, which requires immediate attention. Monitoring the stoma for signs of infection (Choice D) is important but not the priority when compared to a decrease in urinary output. Pouching the stoma with a one-inch margin around it (Choice A) is incorrect as it does not address the issue of decreased urinary output. Referring the client to the United Ostomy Association (Choice B) is not necessary in this immediate situation where a potential complication is suspected.

3. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair.
• B. The assistant inserted two (2) fingers under the proximal end of the stocking.
• C. The assistant elevated the feet while lying down to put on the stockings.
• D. The assistant made sure the toes were warm after putting the stockings on.

Correct answer: A

Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.

4. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. In anorexia nervosa, the body lacks essential nutrients due to severe calorie restriction, leading to dryness and brittleness of the hair. Choices A, B, and C are less likely to directly indicate anorexia nervosa. Preoccupation with calories can be a behavioral symptom, thick body hair is not a typical finding associated with anorexia nervosa, and a sore tongue is more commonly related to nutritional deficiencies like vitamin deficiencies rather than anorexia nervosa.

5. In supply and equipment management, what is the FIRST step in the procurement process?

• A. Keep hand receipts up to date
• B. Establish requirements
• C. Requisition supplies and equipment through the proper channels
• D. Properly receive, inspect, and store required items

Correct answer: B

Rationale: In the procurement process, the FIRST step is to establish requirements. This step involves identifying and defining the needs for supplies and equipment before moving forward with the procurement process. Keeping hand receipts up to date (Choice A) is a task related to tracking and managing inventory but comes after the requirements have been established. Requisitioning supplies and equipment (Choice C) and receiving, inspecting, and storing items (Choice D) are subsequent steps in the procurement process that follow after the requirements have been determined.

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