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. What is the fundamental difference between nursing diagnoses and collaborative problems?

• A. Collaborative problems are managed by nurses using physician-prescribed interventions.
• B. Collaborative problems can be addressed by independent nursing interventions.
• C. Physician-prescribed interventions are incorporated into nursing diagnoses.
• D. Nursing diagnoses include physiologic complications that nurses monitor to detect status changes.

Correct answer: B

Rationale: The correct answer is B, as collaborative problems necessitate the collective expertise and skills of numerous healthcare professionals, including nurses. These problems can be dealt with through independent nursing interventions in cooperation with other team members. Option A is incorrect because collaborative problems aren't strictly managed with physician-prescribed interventions. Option C is incorrect because nursing diagnoses aim at identifying and treating actual or potential health issues, rather than merely integrating physician-prescribed interventions. Option D is incorrect because nursing diagnoses aim at identifying patient issues, not solely physiologic complications, and guide the necessary nursing care, not just monitor for changes.

3. When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

• A. 10-15 seconds
• B. 30-35 seconds
• C. 20-25 seconds
• D. 0-5 seconds

Correct answer: D

Rationale: During endotracheal suctioning, the nurse should apply suctioning while withdrawing and gently rotating the catheter 360 degrees for a short period of 0-5 seconds. This brief duration helps minimize the risk of hypoxia and trauma to the airway. Choices A, B, and C suggest longer time periods for suctioning, which can increase the risk of complications such as hypoxia, mucosal damage, and the removal of excess amounts of airway secretions.

4. This quality is being demonstrated by a Nurse who raise the side rails of a confused and disoriented patient?

• A. Autonomy
• B. Responsibility
• C. Prudence
• D. Resourcefulness

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.

5. What is the most common nutritional disorder for the older adult?

• A. Obesity
• B. Underweight
• C. Vitamin deficiency
• D. Dehydration

Correct answer: A

Rationale: The correct answer is A: Obesity. Among older adults, obesity is the most common nutritional disorder. This is often attributed to reduced physical activity levels and changes in metabolism that occur with aging. Choice B (Underweight) is less common among older adults as compared to obesity. While choices C (Vitamin deficiency) and D (Dehydration) are important nutritional issues, they are generally not as prevalent as obesity in the older adult population.

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