Nursing Elites

1. 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.

2. A healthcare provider is evaluating a client who reports paresthesia of the hands and feet. The provider should identify this manifestation as an indication of which of the following dietary deficiencies?

• A. Iron
• B. Riboflavin
• C. Vitamin C
• D. Vitamin B12

Correct answer: D

Rationale: Correct! Vitamin B12 deficiency can lead to neurological symptoms, including paresthesia (tingling or numbness) of the hands and feet, due to its role in nerve health. Iron deficiency is more commonly associated with anemia symptoms like fatigue and pallor. Riboflavin deficiency can cause mouth and skin changes. Vitamin C deficiency is linked to scurvy symptoms like bleeding gums and easy bruising.

3. Which vitamin is primarily obtained from sunlight exposure?

• A. Vitamin A
• B. Vitamin C
• C. Vitamin D
• D. Vitamin E

Correct answer: C

Rationale: The correct answer is Vitamin D. Vitamin D is synthesized in the skin when it is exposed to sunlight. This process allows the body to produce Vitamin D naturally. Vitamin A (Choice A) is found in foods like liver and carrots and is not primarily obtained from sunlight. Vitamin C (Choice B) is commonly found in fruits and vegetables. Vitamin E (Choice D) is present in foods like nuts and seeds and is not primarily obtained from sunlight.

4. 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.

5. A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?

• A. Formula that remains in the bottle should not be used for one more feeding.
• B. Formula should be changed to whole milk when the infant is 12 months old.
• C. If the infant is gaining weight too rapidly, do not dilute the formula.
• D. If the infant turns away after taking most of the feeding, stop the feeding.

Correct answer: D

Rationale: If the infant turns away after taking most of the feeding, it indicates they are full, and continuing to feed may lead to overfeeding. Choice A is incorrect because it is not safe to use formula that remains in the bottle for another feeding due to the risk of bacterial contamination. Choice B is incorrect as whole milk should be introduced after the infant is 12 months old, not 9 months old. Choice C is incorrect as diluting formula can compromise the infant's nutrition and should not be done without healthcare provider guidance.

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