Nursing Elites

1. When a healthcare professional makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The healthcare professional's attempt to irrigate the tube with 10ml of 0.9% NaCl was unsuccessful, so they determine that the tube was obstructed. Which of the following actions should the healthcare professional take?

• A. Notify the healthcare provider.
• B. Attempt to irrigate the tube with a larger volume of saline.
• C. Replace the NG tube with a new one.
• D. Reposition the client to see if that helps the tube drain.

Correct answer: A

Rationale: If an NG tube is obstructed and cannot be irrigated successfully, notifying the healthcare provider is the appropriate action to take for further management. This is crucial as the healthcare provider may need to assess the situation, provide guidance, or intervene with specific interventions. Attempting to irrigate the tube with a larger volume of saline (Choice B) may exacerbate the situation if the tube is truly obstructed. Replacing the NG tube with a new one (Choice C) should not be the initial action unless advised by the healthcare provider. Repositioning the client (Choice D) may not necessarily resolve the tube obstruction and should not be the primary intervention in this scenario.

2. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?

• A. The nurse washes with her hands held higher than her elbows.
• B. The nurse uses a brush to scrub under her nails.
• C. The nurse washes for at least 30 seconds.
• D. The nurse uses alcohol-based hand rub only.

Correct answer: A

Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.

3. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to

• A. Change whichever item is incorrect to the correct information
• B. Use the bracelet and admission form until a replacement is supplied
• C. Notify the admissions office and wait to apply the bracelet
• D. Make a corrected identification bracelet for the client

Correct answer: C

Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.

4. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump?

• A. 13 ml/hour
• B. 63 ml/hour
• C. 80 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct rate of infusion, divide the total volume by the total time: 250 ml / 4 hours = 62.5 ml/hour, which is rounded up to 63 ml/hour. This rate ensures the proper administration of the KCl over the 4-hour period. Choice A (13 ml/hour) is incorrect as it does not match the calculated rate. Choices C (80 ml/hour) and D (125 ml/hour) are also incorrect as they do not correspond to the calculated rate needed for the specified time frame.

5. During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client’s pulse deficit (per minute)?

• A. 16
• B. 12
• C. 6
• D. 14

Correct answer: A

Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.

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