Nursing Elites

1. What is a true statement about caring for a client with a nasogastric (NG) tube?

• A. The NG tube should be flushed with 30 mL of water every 4 hours.
• B. The client should be positioned in a supine position.
• C. The NG tube should be advanced 5 cm if resistance is met.
• D. The client's nasal mucosa should be inspected daily.

Correct answer: A

Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.

2. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

• A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
• B. Wear clean gloves before inserting the tubing
• C. Position the client on their left side
• D. Hold the solution bag 91 cm (36 inches) above the client's rectum

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

3. When caring for a client with a prescription for wound irrigation, which action should the nurse take?

• A. Use a 10-mL syringe with an 18-gauge needle.
• B. Cleanse the wound from the center outward.
• C. Apply a wet-to-dry dressing.
• D. Pack the wound tightly with gauze.

Correct answer: B

Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.

4. When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?

• A. Deltoid
• B. Ventrogluteal
• C. Vastus lateralis
• D. Dorsogluteal

Correct answer: C

Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.

5. A healthcare provider is providing teaching to a client regarding protein intake. Which of the following foods should the healthcare provider include as an example of an incomplete protein?

• A. Eggs
• B. Soybeans
• C. Lentils
• D. Yogurt

Correct answer: C

Rationale: The correct answer is C: Lentils. Incomplete proteins lack one or more essential amino acids required for protein synthesis in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds. Lentils, a plant-based protein source, are considered incomplete as they do not contain all essential amino acids in sufficient amounts. Choices A, B, and D are incorrect as eggs, soybeans, and yogurt are examples of complete proteins, containing all essential amino acids in the right proportions for the body's needs.

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