Nursing Elites

1. Persons experiencing crisis becomes passive and submissive. As a nurse, you know that the best approach in crisis intervention is to be:

• A. Active and Directive
• B. Passive friendliness
• C. Active friendliness
• D. Firm kindness

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. Why is a pulse oximeter attached to Mr. Dizon's finger?

• A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
• B. To check the level of the patient's tissue perfusion
• C. To measure the effectiveness of the patient's anti-hypertensive medications
• D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop

Correct answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.

3. What should be recommended to help prevent early childhood caries (ECC) in infants?

• A. Avoid giving the infant nighttime bottles
• B. Have the infant drink pasteurized skim milk
• C. Feed the infant iron-rich foods
• D. Give the infant fruit juice to drink

Correct answer: A

Rationale: The correct answer is 'A: Avoid giving the infant nighttime bottles' because prolonged exposure to sugars in milk during the night can lead to caries. Options 'B: Have the infant drink pasteurized skim milk' and 'D: Give the infant fruit juice to drink' are not recommended as they contain sugars that can cause cavities, especially in infants. Option 'C: Feed the infant iron-rich foods' is incorrect because while a balanced diet is important, iron-rich foods do not directly prevent caries development.

4. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

5. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

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