Nursing Elites

1. 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.

2. Which nutrient is critical for wound healing and immune function?

• A. Vitamin B12
• B. Vitamin C
• C. Vitamin D
• D. Vitamin K

Correct answer: B

Rationale: Vitamin C is essential for collagen formation and immune function.

3. Which of the following methods is the best method for determining nasogastric tube placement in the stomach?

• A. X-ray
• B. Observation of gastric aspirate
• C. Testing of pH of gastric aspirate
• D. Placement of external end of tube under water

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?

• A. Apply liberal amount of mineral oil to the area
• B. Use karaya paste and rings around the stoma
• C. Clean the area daily with soap and water before applying bag
• D. Apply talcum powder twice a day

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.

5. A client with stomatitis is receiving teaching from a nurse. Which of the following client statements indicates a need for further teaching?

• A. "I will drink liquids through a straw."?
• B. "I will season foods with dried spices before cooking."?
• C. "I will rinse my mouth with baking soda and water frequently."?
• D. "I will eat frozen bananas as a snack."?

Correct answer: C

Rationale: The correct answer is, "I will rinse my mouth with baking soda and water frequently."? Stomatitis is an inflammation of the mucous lining in the mouth, and rinsing with baking soda and water can be too abrasive and further irritate the condition. Choices A, B, and D are appropriate self-care measures for a client with stomatitis and do not indicate a need for further teaching.

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