Nursing Elites

1. A nurse that is always ready to answer for all his actions and decision is said to be:

• A. Accountable C. Critical thinker
• B. Responsible D. Assertive
• C.
• D.

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. Which nursing diagnosis has nutritional implications?

• A. impaired dentition
• B. disruption of gas exchange
• C. self-esteem disturbance
• D. sleep pattern disturbance

Correct answer: A

Rationale: Impaired dentition affects a patient's ability to chew and consume a variety of foods, leading to potential nutritional deficiencies and malnutrition.

3. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

4. A client has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?

• A. Replace the bag and tubing every 24 hours
• B. Flush the tubing with 10 mL water every 6 hours
• C. Administer the feeding by gravity drip
• D. Heat the formula prior to infusion

Correct answer: B

Rationale: To prevent clogging when using high-viscosity formulas in a small-bore jejunostomy, the nurse should flush the tubing with 10 mL of water every 6 hours. This action helps maintain tube patency and prevent blockages. Replacing the bag and tubing every 24 hours (Choice A) is unnecessary and does not specifically address preventing clogging. Administering the feeding by gravity drip (Choice C) or heating the formula prior to infusion (Choice D) are not effective interventions for preventing tubing clogging.

5. A child with ear problem should be assessed for the following, EXCEPT:

• A. is there any fever?
• B. Ear discharge
• C. If discharge is present for how long?
• D. Ear pain

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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