Nursing Elites

1. A client who has dumping syndrome following a hemi-colectomy should avoid which of the following foods when receiving nutritional teaching from a nurse?

• A. Rice
• B. Poached eggs
• C. Fresh apples
• D. White bread

Correct answer: C

Rationale: Fresh apples should be avoided by a client with dumping syndrome following a hemi-colectomy because they are high in fiber and can exacerbate gastrointestinal symptoms such as diarrhea and bloating. Rice and poached eggs are good options as they are easily digestible and less likely to trigger dumping syndrome symptoms. White bread is also preferable over whole grain bread due to its lower fiber content, making it a better choice for individuals with dumping syndrome.

2. Are the following statements both true: 'Most excess energy intake, whether from protein, carbohydrate, alcohol, or fat, is stored in the liver' and 'Fat is a good source of energy, but the preferred fuel is protein'?

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true, but the second is false
• D. The first statement is false, but the second is true

Correct answer: B

Rationale: Both of the given statements are false. The first statement is inaccurate because the primary location for excess energy storage is not the liver, but rather adipose tissue where it is stored as fat. While the liver does have a role in energy storage and metabolism, it is not the main storage site for excess intake. The second statement is also incorrect. Although fat and protein can be used as sources of energy, the body's preferred source of energy is carbohydrates. They break down more efficiently and are easier for the body to use. The body prefers to conserve protein for other essential functions, such as tissue repair and the production of enzymes. Therefore, protein is not the preferred fuel source.

3. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

4. Furosemide (Lasix) is a drug used to _____.

• A. activate vitamin D
• B. stimulate appetite
• C. lower cholesterol
• D. mobilize fluids

Correct answer: D

Rationale: Furosemide is a diuretic that helps mobilize fluids by increasing urine output, often used to treat conditions like edema and heart failure.

5. When taking a blood pressure reading, where should the cuff be positioned?

• A. The cuff should be deflated fully before immediately starting a second reading for the same patient
• B. The cuff should be deflated quickly after being inflated to 180 mmHg
• C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
• D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery

Correct answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

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