Nursing Elites

1. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

2. A client has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?

• A. Replace the bag and tubing every 24 hours
• B. Flush the tubing with 10 mL water every 6 hours
• C. Administer the feeding by gravity drip
• D. Heat the formula prior to infusion

Correct answer: B

Rationale: To prevent clogging when using high-viscosity formulas in a small-bore jejunostomy, the nurse should flush the tubing with 10 mL of water every 6 hours. This action helps maintain tube patency and prevent blockages. Replacing the bag and tubing every 24 hours (Choice A) is unnecessary and does not specifically address preventing clogging. Administering the feeding by gravity drip (Choice C) or heating the formula prior to infusion (Choice D) are not effective interventions for preventing tubing clogging.

3. A patient with an ileostomy is suffering from frequent diarrhea. The clinician should advise the patient to increase his intake of what food to thicken stool output?

• A. celery
• B. salad greens
• C. potatoes
• D. dried beans and peas

Correct answer: C

Rationale: Potatoes are starchy and can help thicken stool output, making them beneficial for patients with an ileostomy experiencing diarrhea.

4. Which monosaccharide is the most sweet?

• A. Glucose
• B. Dextrose
• C. Fructose
• D. Sucrose

Correct answer: C

Rationale: Fructose is the sweetest of the monosaccharides. Note that glucose and dextrose are the same, and sucrose is a disaccharide, not a monosaccharide.

5. Causes of acute renal failure include:

• A. chronic renal failure
• B. uncontrolled diabetes mellitus
• C. recurrent urinary tract infections
• D. severe injury such as extensive burns

Correct answer: D

Rationale: The correct answer is D. Severe injuries, like extensive burns, can cause acute renal failure due to shock, reduced blood flow to the kidneys, and tissue damage. Choices A, B, and C are incorrect because chronic renal failure, uncontrolled diabetes mellitus, and recurrent urinary tract infections are more likely to contribute to chronic kidney disease rather than acute renal failure.

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