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. A nurse is educating the parent of a preschool-age child about nutrition. Which is the best snack choice for the nurse to recommend to the parent?

• A. Fruit snacks
• B. Mini wheat bagel with peanut butter
• C. White toast with jelly
• D. Sports drink

Correct answer: B

Rationale: The best snack choice for a preschool-age child recommended by the nurse would be a mini wheat bagel with peanut butter. This option provides a good balance of carbohydrates, protein, and healthy fats, making it a more nutritious choice compared to the other options. Fruit snacks may contain added sugars and lack essential nutrients. White toast with jelly is high in simple carbohydrates and sugars, providing less sustained energy. Sports drinks are often high in sugar and not necessary for a preschool-age child's snack.

3. What is a major constituent of cell membranes?

• A. cholesterol
• B. phospholipid
• C. saturated
• D. triglyceride

Correct answer: B

Rationale: Phospholipids are a major component of cell membranes, providing structural integrity and facilitating cell signaling. Cholesterol (choice A) is also present in cell membranes but in smaller amounts and plays a different role. Saturated (choice C) and triglyceride (choice D) are not major constituents of cell membranes.

4. A client who underwent surgical placement of a colostomy is being cared for by a nurse. Which of the following statements indicates the client understands the dietary teaching?

• A. "Eating yogurt can help decrease the amount of gas that I have."?
• B. "I should eliminate pasta from my diet so that I don't have as many loose stools."?
• C. "My largest meal of the day should be in the evening."?
• D. "Carbonated beverages can help control odor."?

Correct answer: D

Rationale: The correct answer is D. Carbonated beverages can help control odor in clients with colostomies. This is because carbonated drinks can help decrease odor by reducing the production of odoriferous compounds in the colon. Choices A, B, and C are incorrect. Eating yogurt may help regulate bowel movements but does not specifically address odor control associated with colostomies. Eliminating pasta from the diet to reduce loose stools is not necessary for colostomy care. The timing of the largest meal of the day is not directly related to dietary teaching for colostomy care.

5. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

• A. inconsistent
• B. low systolic and high diastolic
• C. higher than what the reading should be
• D. lower than what the reading should be

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.

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