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. What type of diet would most likely benefit a patient with cystic fibrosis?

• A. Low sodium
• B. Low fat
• C. Clear liquid
• D. High calorie, high protein

Correct answer: D

Rationale: Patients with cystic fibrosis often have malabsorption issues, leading to increased energy needs. A high-calorie, high-protein diet is recommended to help meet these needs, support growth, and maintain overall health. Choices A, B, and C do not address the specific dietary requirements associated with cystic fibrosis, making them less beneficial for these patients.

3. A nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes mellitus. The nurse should explain that which of the following sweeteners will add calories to the client's carbohydrate count?

• A. Sorbitol
• B. Sucralose
• C. Aspartame
• D. Acesulfame potassium

Correct answer: A

Rationale: Sorbitol is a sweetener that will add calories to the client's carbohydrate count. It is a sugar alcohol that provides about 2.6 calories per gram. Sucralose, aspartame, and acesulfame potassium are all non-nutritive sweeteners that do not contribute significant calories to the diet. Sucralose is about 600 times sweeter than sucrose but does not add calories. Aspartame is a low-calorie sweetener that is approximately 200 times sweeter than sucrose, and acesulfame potassium is a calorie-free sweetener.

4. After bronchoscopy, the nurse's priority is to check which of the following before feeding?

• A. Gag reflex
• B. Wearing off of anesthesia
• C. Swallowing reflex
• D. Peristalsis

Correct answer: A

Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.

5. What are the responsibilities of a nurse towards a patient?

• A. A registered nurse is responsible for a group of patients from their admission to their discharge
• B. A registered nurse only provides care for the patient with the assistance of nursing aides
• C. A nurse's only responsibility is to perform administrative duties in a healthcare setting
• D. A nurse's only responsibility is to maintain hospital equipment

Correct answer: A

Rationale: A registered nurse is responsible for a group of patients from their admission to their discharge. This responsibility encompasses assessing patient needs, formulating care plans, administering medications, monitoring patient progress, and coordinating with other members of the healthcare team. Choice B is not entirely accurate because, even though nurses often work with nursing aides, the nurses themselves hold the ultimate responsibility for the overall care of the patient. Choices C and D are incorrect as they depict an incomplete and inaccurate representation of a nurse's role, which extends beyond administrative duties and equipment maintenance to primarily focus on direct patient care.

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