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 client has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

• A. Assign an assistive personnel to feed the client.
• B. Explain to the client that their tray is here and guide their hands to it.
• C. Describe to the client the location of the food on the tray.
• D. Ask the client if they would prefer a liquid diet.

Correct answer: C

Rationale: When a client has bilateral eye patches, promoting independence in eating is crucial to maintain dignity and autonomy. Describing the location of the food on the tray enables the client to locate and feed themselves. Assigning assistive personnel to feed the client (Choice A) takes away their independence. Merely informing the client that the tray is here and guiding their hands to it (Choice B) does not empower the client to eat independently. Asking if the client prefers a liquid diet (Choice D) is not directly addressing the client's ability to independently eat the current meal.

3. Churns chyme and has an environment of pH2; holds 4-6 cups of food:

• A. stomach
• B. pancreas
• C. large intestine
• D. small intestine

Correct answer: A

Rationale: The stomach churns food into chyme and has a highly acidic environment (pH 2) to aid in the digestion of proteins and other nutrients.

4. What type of drug therapy is typically administered immediately after a heart attack?

• A. Antilipemic drugs
• B. Corticosteroids
• C. Diuretics
• D. Thrombolytic drugs

Correct answer: D

Rationale: Thrombolytic drugs are typically administered immediately after a heart attack to dissolve the clot blocking the coronary artery and restore blood flow to the heart muscle. Antilipemic drugs are used to lower lipid levels and prevent atherosclerosis, but they are not typically administered immediately after a heart attack. Corticosteroids are used to reduce inflammation and suppress the immune response, which are not immediate concerns after a heart attack. Diuretics are used to reduce fluid build-up and lower blood pressure, but these are not the primary concerns immediately following a heart attack.

5. A nurse is caring for a client with a major burn injury and is receiving TPN. Which of the following lab tests is the priority for the nurse to use to confirm the client is receiving adequate nutrition?

• A. Iron
• B. Magnesium
• C. Folic acid
• D. Prealbumin

Correct answer: D

Rationale: Prealbumin is a sensitive indicator of protein status and nutrition, making it a priority for assessing nutritional adequacy in clients receiving TPN. Iron, magnesium, and folic acid levels are important for overall health but do not specifically indicate nutritional adequacy in the context of TPN administration.

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