Nursing Elites

1. Mang Carlos has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

• A. Give extraordinary measures to save Mang Carlos
• B. Stay with Mang Carlos and Do nothing
• C. Call the physician
• D. Activate Code Blue

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. After bronchoscopy, the nurse's priority is to check which of the following before feeding?

• A. Gag reflex
• B. Wearing off of anesthesia
• C. Swallowing reflex
• D. Peristalsis

Correct answer: A

Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.

3. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

• A. severity of illness
• B. presence of pressure sores
• C. localized edema
• D. generalized weakness

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

4. A pregnant woman has applied to use WIC services to supplement her food intake. The WIC program would provide vouchers for _____ in this situation.

• A. lean beef
• B. fruit-flavored yogurt
• C. whole grain bread
• D. refried beans

Correct answer: C

Rationale: The correct answer is C: whole grain bread. The WIC program aims to provide nutritious foods to support a healthy diet during pregnancy. Whole grain bread is a good source of fiber and essential nutrients. Choice A, lean beef, is a protein source but may not be as versatile as whole grain bread in providing a variety of nutrients essential during pregnancy. Choice B, fruit-flavored yogurt, may contain added sugars and may not offer the same level of essential nutrients as whole grain bread. Choice D, refried beans, is a good source of protein and fiber, but whole grain bread is often a staple recommended in pregnancy for its nutritional benefits.

5. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

• A. Client lying on his back then flat on his abdomen on Trendelenburg position
• B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
• C. Client lying flat on his back and then flat on his abdomen
• D. Client lying on his right then left side on Trendelenburg position

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

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