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. An elderly man is hospitalized with a diagnosis of malnutrition three months following his wife's death. What risk factor for malnutrition does this scenario illustrate?

• A. A history of chronic illness
• B. Depression or social isolation
• C. Age
• D. Impaired mobility

Correct answer: B

Rationale: This scenario illustrates depression or social isolation as a risk factor for malnutrition. After the death of his wife, the elderly man may have experienced depression or social isolation, which can lead to decreased food intake and poor nutritional status. Although age, chronic illness, and impaired mobility can also contribute to malnutrition, they are not the primary factors described in this scenario. The history of chronic illness (Choice A) and impaired mobility (Choice D) were not mentioned in the scenario, and while age (Choice C) is a factor, it's not the main factor depicted in this case.

3. An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?

• A. Marijuana
• B. Amphetamines
• C. Barbiturates
• D. Anxiolytics

Correct answer: A

Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.

4. Which of the following is a normal finding during assessment of a Chest tube in a 3 way bottle system?

• A. There is a continuous bubbling in the drainage bottle
• B. There is an intermittent bubbling in the suction control bottle
• C. The water fluctuates during inhalation of the patient
• D. There is 3 cm of water left in the water seal bottle

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. Which vitamin is crucial for collagen synthesis and wound healing?

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

Correct answer: A

Rationale: The correct answer is Vitamin C. Vitamin C is crucial for collagen synthesis, a process important for wound healing. Collagen is a key protein that helps in wound repair and tissue strength. Vitamin D is primarily known for its role in calcium absorption and bone health, not directly related to collagen synthesis. Vitamin E is an antioxidant that helps protect cells from damage but is not directly involved in collagen synthesis. Vitamin K is essential for blood clotting but does not play a major role in collagen synthesis for wound healing.

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