Nursing Elites

1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

• A. severity of illness
• B. presence of pressure sores
• C. localized edema
• D. generalized weakness

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

2. Each of the following describes the physiologic roles of water, except one. Which is the exception?

• A. Acts as a solvent for chemical reactions.
• B. Maintains stability of body fluids.
• C. Enables transport of nutrients and excretion of waste.
• D. Regulates temperature by pooling as perspiration on skin.

Correct answer: D

Rationale: The correct answer is D. Water regulates body temperature by evaporating as perspiration from the skin, not by pooling. When sweat evaporates from the skin, it takes away heat, which helps cool the body. Choices A, B, and C are correct because water acts as a solvent for chemical reactions, maintains the stability of body fluids, and enables the transport of nutrients and excretion of waste, respectively.

3. Which of the following gauges should you prepare for spinal anesthesia if the anesthesiologist requires a pink spinal set and a blue spinal set as backup?

• A. Gauges 16 and 22
• B. Gauges 18 and 16
• C. Gauges 16 and 20
• D. Gauges 25 and 22

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

5. To prevent baby bottle tooth decay, what should the nurse instruct?

• A. Water
• B. Milk
• C. Iron-fortified formula
• D. Unsweetened fruit juice

Correct answer: A

Rationale: The correct answer is A: Water. Water is the best choice to prevent baby bottle tooth decay as it does not cause tooth decay and is a good option for bedtime bottles. Milk (choice B) and iron-fortified formula (choice C) contain sugars that can contribute to tooth decay. Unsweetened fruit juice (choice D) also contains natural sugars that can be harmful to the baby's teeth.

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