Nursing Elites

1. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

• A. Lubricates the tip of the catheter prior to inserting into the stoma
• B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
• C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
• D. Clamps of the flow of fluid when felling uncomfortable

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. What primarily determines the Dietary Reference Intake (DRI) for protein?

• A. Intake of fatty acids
• B. Gender
• C. Height
• D. Body weight

Correct answer: D

Rationale: The Dietary Reference Intake (DRI) for protein is primarily determined by an individual's body weight. This is because the body's protein requirement is proportionate to its size, which is generally reflected in the body weight. Therefore, choice D is correct. Choices A, B, and C are incorrect: While factors such as fatty acid intake, gender, and height can influence an individual's overall nutritional needs, they do not directly determine the DRI for protein.

3. A nurse is caring for four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?

• A. A client who is postoperative following a laminectomy and is receiving IV PCA
• B. A client who has dysphagia and does not recognize his family
• C. A client who has COPD and is going home with oxygen
• D. A client who has colon cancer and will undergo a hemicolectomy

Correct answer: D

Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible. Choices A, B, and C do not typically require TPN. Choice A is managing postoperative pain with IV PCA, choice B is likely to need alternative feeding methods due to dysphagia, and choice C is going home with oxygen for COPD management, which does not directly relate to the need for TPN.

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. When rickets occurs, how is the alveolar bone affected compared to other bones in the body?

• A. Both statements are true.
• B. Both statements are false.
• C. The first statement is true; the second is false.
• D. The first statement is false; the second is true.

Correct answer: A

Rationale: Both statements are true. When rickets occurs, the alveolar bone is affected similar to other bones in the body, with the trabeculae of the alveolar bone also weakening. In addition to damaged alveolar bone caused by vitamin D deficiency, dental changes include delayed dentition and small molars. The other choices are incorrect because both statements provided are accurate based on the effects of rickets on the alveolar bone.

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