Nursing Elites

1. To ensure client safety before starting blood transfusions, the following are needed before the procedure can be done EXCEPT:

• A. take baseline vital signs
• B. warm the blood to room temperature for 30 minutes before administering the transfusion
• C. have two nurses verify client identification, blood type, unit number, and expiration date of blood
• D. get consent signed for blood transfusion

Correct answer: D

Rationale: To ensure client safety before starting blood transfusions, taking baseline vital signs, warming the blood to room temperature, and having two nurses verify client identification, blood type, unit number, and expiration date of blood are crucial steps. Consent for blood transfusion is required but is typically obtained before the procedure. The focus before the procedure should be on confirming the right client, blood product, and ensuring the blood is prepared correctly to minimize risks of transfusion reactions.

2. The nurse is educating a client about foods high in antioxidants A and C. Which breakfast items chosen by the client would indicate that the education was sufficient?

• A. Fried eggs, sausage, and whole wheat toast
• B. Oatmeal with blueberries and coffee
• C. Cereal with strawberries and low-fat milk
• D. Hard-boiled eggs, cantaloupe, and orange juice

Correct answer: D

Rationale: Hard-boiled eggs, cantaloupe, and orange juice are high in antioxidants A and C.

3. In a patient with liver cirrhosis, weight gain due to fluid retention can mask the symptoms of what condition?

• A. Liver failure
• B. Gallbladder disease
• C. Heart failure
• D. Protein-Energy Malnutrition (PEM)

Correct answer: D

Rationale: In a patient with liver cirrhosis, weight gain due to fluid retention can mask Protein-Energy Malnutrition (PEM) symptoms. This can lead to an increase in weight, making it challenging to identify weight loss or muscle wasting associated with PEM. Therefore, option D is correct. Options A, B, and C are incorrect because fluid retention and weight gain related to liver cirrhosis do not necessarily hide the symptoms of liver failure, gallbladder disease, or heart failure.

4. A client with iron deficiency anemia is being taught about dietary recommendations by a nurse. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron?

• A. Tomato juice
• B. Tea
• C. Milk
• D. Dried Beans

Correct answer: A

Rationale: Tomato juice is the correct answer because it contains vitamin C, which enhances the absorption of nonheme iron. Vitamin C helps convert nonheme iron into a form that is easier for the body to absorb. Tea and milk should be avoided when consuming nonheme iron as they can inhibit iron absorption. Dried beans, although a good source of iron, do not enhance iron absorption when consumed with nonheme iron.

5. What is the procedure called when direct observations are used to generate an estimate of a client's current food intake?

• A. Food diary
• B. 24-hour recall
• C. Kilocalorie count
• D. Nutrient surveillance record

Correct answer: C

Rationale: A kilocalorie count is the correct answer as it involves directly observing a client's food intake, which is often used in hospitals to accurately assess nutritional intake and ensure it meets dietary requirements. A food diary (Choice A) is typically self-reported by the client and not directly observed. A 24-hour recall (Choice B) is also usually self-reported and relies on a client's memory of the past 24 hours, which can be unreliable. A nutrient surveillance record (Choice D) is a broader term for tracking nutrient intake in a population and is not specific to the direct observation of an individual's food intake.

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