Nursing Elites

1. Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?

• A. Maintain a constant connection to low-intermittent suction
• B. Irrigate the tube as per physician's order
• C. Suction the mouth and nose every shift
• D. Perform a daily fecal occult blood sample

Correct answer: B

Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting. To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (Choice A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (Choice C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (Choice D) is unrelated to maintaining the patency of a nasogastric tube.

2. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?

• A. Irregular breathing patterns
• B. Minimal heartbeat, dilated pupils
• C. Relaxed muscles, regular breathing, constricted pupils
• D. Euphoria, drowsiness, dizziness

Correct answer: D

Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.

3. Albert is a patient in the hospital who is scheduled for surgery the following morning. After the pre-operative visit from the anesthesia staff member who has obtained surgical consent, Albert asks for an explanation of what type of surgery he is going to have. He states that he's not sure what he just signed. What is your best response?

• A. Don't worry, they'll explain it in the operating room.
• B. It's standard procedure to get the consent; you don't need to worry.
• C. Let me ask the nurse anesthetist to come back and explain it further.
• D. Someone will review it with you prior to surgery.

Correct answer: C

Rationale: The correct response is to ensure that the patient fully understands the nature of the surgery they are about to undergo. If the patient expresses uncertainty about the procedure they signed consent for, it indicates a lack of informed consent, which is essential before any surgery. By requesting the nurse anesthetist to return and provide a more detailed explanation, the patient can make an informed decision. Choices A, B, and D do not address the issue of the patient's lack of understanding and the need for informed consent, making them incorrect. Option C is the best course of action to rectify the situation and ensure the patient's understanding and consent are properly obtained.

4. Becky is a 17-year-old type I diabetic who has been admitted for her third episode of diabetic ketoacidosis (DKA) since being diagnosed last year. She states that she hates feeling different from her friends and refuses to take her insulin as recommended. What would be the most helpful action for Becky?

• A. Scolding her for not taking her insulin
• B. Recommending that she use an insulin pump
• C. Contacting the local support group for diabetic teens
• D. Telling her parents they must provide more strict oversight

Correct answer: C

Rationale: Contacting the local support group for diabetic teens would be the most helpful action for Becky. By reaching out to see if another diabetic teenager could provide support, Becky would have the opportunity to connect with someone in her peer group who faces similar challenges. This connection can help reduce her sense of isolation and the feeling of being 'different.' Choice A, 'Scolding her for not taking her insulin,' is inappropriate and could further alienate Becky. It does not address the underlying emotional issues driving her behavior. Choice B, 'Recommending that she use an insulin pump,' does not directly address Becky's emotional struggle with feeling different from her friends. While an insulin pump may be a helpful tool, it does not tackle the root cause of her non-compliance. Choice D, 'Telling her parents they must provide more strict oversight,' focuses on imposing stricter control without addressing Becky's emotional needs or offering peer support, which may not be effective in improving her insulin adherence in the long term.

5. A nursing student is teaching a patient and family about epilepsy prior to the patient's discharge. For which statement should you intervene?

• A. "You should avoid consumption of all forms of alcohol."?
• B. "Wear your medical alert bracelet at all times."?
• C. "Protect your loved one's airway during a seizure."?
• D. "It's important to consult with your physician before taking over-the-counter medications."?

Correct answer: D

Rationale: The correct answer is, "It's important to consult with your physician before taking over-the-counter medications."? Patients with epilepsy should not take over-the-counter medications without medical advice due to potential interactions with antiepileptic drugs or triggering seizures. Choices A, B, and C are all appropriate statements for a patient with epilepsy, focusing on alcohol avoidance, wearing a medical alert bracelet, and airway protection during a seizure, respectively. Choice D is incorrect because patients with epilepsy need to be cautious about medications due to possible interactions or adverse effects, so consulting with a physician is crucial before taking over-the-counter medications.

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