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. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

• A. Specimen is collected after meals
• B. The nurse puts the Clinitest tablet into a test tube
• C. She added 5 drops of urine and 10 drops of water
• D. If the color becomes orange or red, it is considered

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading. Choice A is incorrect as the specimen should be collected before meals for accurate results. Choice B is incorrect as it should be the Clinitest tablet, not the clingiest tablet. Choice D is incorrect as the statement is incomplete and lacks clarity.

3. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.

4. Which of the following is a primary factor that affects blood pressure?

• A. Obesity
• B. Age
• C. Stress
• D. Gender

Correct answer: A

Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure, but obesity has a more direct and significant impact on increasing blood pressure levels compared to the other factors listed.

5. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The position that best shows chest expansion as well as its movements is when the client is sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B (Prone) and Choice D (Supine) involve positions where the chest's movements and expansion are less visible and may not provide an accurate representation of respiratory function. Choice C (Sidelying) can also limit the visibility of chest expansion compared to the sitting position.

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