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 medical term for a persistent, abnormal distortion of taste?

• A. Anosmia
• B. Dysgeusia
• C. Xerostomia
• D. Hypogeusia

Correct answer: B

Rationale: The correct answer is Dysgeusia, which is a persistent and abnormal distortion of the sense of taste. This condition can be triggered by various factors such as medications or certain diseases. Anosmia, choice A, refers to the loss of the sense of smell, not taste. Xerostomia, choice C, is the medical term for dry mouth, which is not specifically related to a distortion of taste. Hypogeusia, choice D, refers to a reduced ability to taste things, which is not the same as a distortion of the sense of taste.

3. A client who is 2 days postoperative following abdominal surgery is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

• A. Cranberry juice
• B. Flavored gelatin
• C. Skim milk
• D. Chicken broth

Correct answer: A

Rationale: Cranberry juice is an appropriate choice for a client transitioning from a clear liquid diet to full liquids post abdominal surgery. It provides hydration and some essential nutrients. Flavored gelatin is usually allowed on a clear liquid diet and may not be suitable for a full liquids phase. Skim milk and chicken broth are typically introduced in a later stage of the diet progression, closer to a soft diet, due to their higher protein and fat content.

4. Has Healthy People (HP 2020), issued by the U.S. Department of Health and Human Services, resulted in a reduction of deaths from cardiovascular disease, stroke, and some cancers, as well as decreased dental caries in children aged 2 to 4 years and adults aged 53 to 44 years?

• A. Yes, both statements are true.
• B. No, both statements are false.
• C. The first statement is true; the second is false.
• D. The first statement is false; the second is true.

Correct answer: B

Rationale: Both statements are false. While Healthy People (HP 2020) has contributed to a reduction in deaths from cardiovascular disease, stroke, and some cancers, it did not result in decreased dental caries in children aged 2 to 4 years and adults aged 53 to 44 years. Therefore, the correct answer is B. Choice A is incorrect because the second statement is false. Choice C is incorrect as the first statement is also false. Choice D is incorrect as the second statement is false.

5. When taking a blood pressure reading, where should the cuff be positioned?

• A. The cuff should be deflated fully before immediately starting a second reading for the same patient
• B. The cuff should be deflated quickly after being inflated to 180 mmHg
• C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
• D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery

Correct answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

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