Nursing Elites

1. Which nursing diagnosis has nutritional implications?

• A. impaired dentition
• B. disruption of gas exchange
• C. self-esteem disturbance
• D. sleep pattern disturbance

Correct answer: A

Rationale: Impaired dentition affects a patient's ability to chew and consume a variety of foods, leading to potential nutritional deficiencies and malnutrition.

2. The nurse knows that after receiving the blood from the blood bank, it should be administered within:

• A. 1 hour
• B. 2 hours
• C. 4 hours
• D. 6 hours

Correct answer: D

Rationale: Blood transfusions need to be administered promptly after receiving the blood from the blood bank to ensure patient safety and effectiveness. Waiting too long can lead to complications such as bacterial growth in the blood product, which can be harmful when infused. Administering the blood within 6 hours is crucial to prevent such risks. Choices A, B, and C are incorrect because waiting for 1, 2, or 4 hours respectively can increase the likelihood of complications associated with delayed transfusion.

3. Which type of assessment evaluates a person's risk of malnutrition by ranking key variables from the medical history and physical examination?

• A. Katz index
• B. integrated assessment
• C. subjective global assessment
• D. nutrition care plan

Correct answer: C

Rationale: The Subjective Global Assessment (SGA) is the correct choice. SGA is a comprehensive tool used to assess an individual's risk of malnutrition by integrating key variables from the medical history, physical examination, and other relevant factors. The Katz index is used to assess activities of daily living, not malnutrition risk. An integrated assessment refers to the overall evaluation process involving multiple assessments. A nutrition care plan is a personalized plan developed based on assessment findings, not the assessment itself.

4. Cyanocobalamin is a form of which vitamin?

• A. Vitamin B1
• B. Vitamin B2
• C. Vitamin B3
• D. Vitamin B12

Correct answer: D

Rationale: Cyanocobalamin is a synthetic form of Vitamin B12. Vitamin B12 is essential for various bodily functions, including red blood cell formation, neurological function, and DNA synthesis. It is not to be confused with Vitamin B1, B2, or B3, which are separate vitamins with different roles in the body.

5. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

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