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. Hypertrophic burn scars are caused by:

• A. exaggerated contraction
• B. random layering of collagen
• C. wound ischemia
• D. delayed epithelialization

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.

3. The most significant factor that might affect the nurse’s care for the psychiatric patient is:

• A. Nurse’s own beliefs and attitude about the mentally ill
• B. Amount of experience he has with psychiatric clients
• C. Her abilities and skill to care for the psychiatric clients
• D. Her knowledge in dealing with the psychiatric clients

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. Each of the following is a form of vitamin K, except one. Which is the exception?

• A. Phylloquinone
• B. Tocopherol
• C. Menaquinone
• D. Menadione

Correct answer: B

Rationale: Tocopherol, Choice B, is not a form of vitamin K; it is another name for vitamin E. Phylloquinone (Choice A), menaquinone (Choice C), and menadione (Choice D) are all forms of vitamin K. Phylloquinone is vitamin K1 found in green plants, menaquinone is vitamin K2 produced in the large intestine and found in animal tissues, and menadione is a synthetic form of vitamin K. Therefore, Choice B is the correct answer because it does not belong to the vitamin K group, unlike the other options.

5. What instruction should the nurse include on weight gain during pregnancy?

• A. Failure to obtain the required weight gain during pregnancy will increase the risk of preterm birth.
• B. An obese client needs to gain as much weight as a client with a normal body mass index.
• C. A client with a normal body mass index should plan on gaining 50 pounds.
• D. Clients will need to eat for two when they are pregnant.

Correct answer: A

Rationale: Appropriate weight gain is crucial for reducing the risk of preterm birth.

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