Nursing Elites

1. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

• A. Oliguria and jaundice
• B. Urticaria and wheezing
• C. Headache, chills, & fever
• D. Hypertension and flushing

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. A client is receiving education from a nurse regarding the dietary changes needed for weight loss. Which of the following actions should the nurse perform first?

• A. Educate the client about daily caloric requirements.
• B. Determine the client’s daily caloric intake.
• C. Provide the client with meal planning information.
• D. Show the client how to identify the fat content of packaged foods.

Correct answer: B

Rationale: The correct answer is to determine the client’s daily caloric intake first. This step is crucial in understanding the client's current dietary habits and establishing a baseline for creating an effective weight loss plan. Educating the client about daily caloric requirements (Choice A) can only be done effectively after knowing the client's current intake. Providing meal planning information (Choice C) and teaching the client how to identify fat content in foods (Choice D) come after determining the baseline caloric intake to tailor the plan accordingly.

3. Scurvy is caused by a deficiency of ascorbic acid (Vitamin C) because ascorbic acid is required for collagen synthesis. Is this statement true or false?

• A. TRUE
• B. FALSE
• C. Not applicable
• D. Not applicable

Correct answer: A

Rationale: The statement is accurate. Scurvy is indeed caused by a deficiency in ascorbic acid, which is another name for Vitamin C. This vitamin plays a crucial role in the synthesis of collagen, a protein that helps in the formation and strength of skin, blood vessels, tissues, and bones. When the body lacks Vitamin C, it cannot produce enough collagen, leading to symptoms associated with scurvy such as bleeding gums and weakened immunity. The choice 'False' is incorrect because it contradicts the proven medical and scientific understanding of the causes of scurvy. Choices 'C' and 'D' are marked as 'Not applicable' because the question only requires a true or false answer.

4. In conducting a cleansing enema, how does the nurse position the client?

• A. Right lateral position
• B. Left lateral position
• C. Right Sim's position
• D. Left Sim's position

Correct answer: B

Rationale: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.

5. Because of increasing cases of fluorosis, low levels of fluoride are added to commercial infant formula. Breast milk provides low levels of fluoride.

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

Correct answer: D

Rationale: The first statement is false; fluoride is not added to infant formulas due to the risk of fluorosis. The second statement is true; breast milk contains low levels of fluoride.

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