Nursing Elites

1. Which of the following is NOT a part of a process recording?

• A. Non-verbal narrative account
• B. Analysis and interpretation
• C. Audio-visual recording
• D. Verbal narrative account

Correct answer: C

Rationale: A process recording typically includes a non-verbal narrative account (Choice A), an analysis and interpretation (Choice B), and a verbal narrative account (Choice D). These components help in providing a comprehensive assessment of a patient's condition and ensuring that interventions are appropriately targeted for optimized outcomes. An audio-visual recording (Choice C), while it can be a part of some data collection processes, is not typically included in a process recording, making it the correct answer.

2. A client with Crohn's disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?

• A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
• B. Remove unused parenteral nutrition after 12 hours of use.
• C. Monitor daily laboratory values and report abnormalities as needed.
• D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.

Correct answer: B

Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.

3. In a patient with chronic kidney disease, which dietary modification is recommended?

• A. Increase protein intake
• B. Reduce potassium intake
• C. Increase sodium intake
• D. Reduce fiber intake

Correct answer: B

Rationale: Reducing potassium intake is important for patients with chronic kidney disease to prevent hyperkalemia.

4. A client states they are taking greater than the recommended daily allowance of vitamin E to prevent cataracts. Which complication should the nurse educate the client as related to taking excessive amounts of vitamin E?

• A. Lung cancer
• B. Stroke
• C. Diarrhea
• D. Liver damage

Correct answer: B

Rationale: The correct answer is B: Stroke. High doses of vitamin E supplements have been associated with an increased risk of hemorrhagic stroke due to its blood-thinning properties. Option A, lung cancer, is not a known complication of excessive vitamin E intake. Option C, diarrhea, is more commonly associated with excessive intake of other vitamins or minerals. Option D, liver damage, is not a commonly reported complication of vitamin E overdose.

5. The nurse is working with a patient who recently had a stroke. The patient frequently chokes and coughs when eating and is having difficulty feeding herself. What is the best way to ensure adequate nutrition?

• A. to have an aide feed her at each meal
• B. to ask a family member to assist during meals
• C. to provide tube feedings for the patient
• D. to initiate TPN for the patient

Correct answer: C

Rationale: The best way to ensure adequate nutrition for a stroke patient who frequently chokes and coughs when eating and has difficulty feeding herself is to provide tube feedings. Tube feedings are a safe and effective method to deliver nutrition directly to the stomach or intestines, bypassing the swallowing mechanism, reducing the risk of aspiration. Having an aide feed her each meal (choice A) may not address the underlying issue of swallowing difficulty and aspiration risk. Asking a family member to be present at each meal (choice B) does not provide a definitive solution to the patient's nutritional needs. Placing the patient on total parenteral nutrition (TPN) (choice D) is a more invasive and typically reserved for patients who cannot tolerate enteral feedings or have non-functional gastrointestinal tracts.

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