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 client who 1) _____ diet requires 2) ___ amounts of vitamin C.

• A. A) Follows a vegan diet, B) More
• B. B) Smokes cigarettes, B) More
• C. A) Follows a vegan diet, C) The same
• D. B) Smokes cigarettes, C) The same

Correct answer: B

Rationale: The correct answer is B) Smokes cigarettes, More. Smoking increases the need for vitamin C as it can deplete the body's vitamin C levels. Vegan diets, on the other hand, require more vitamin C for optimal absorption due to the absence of heme iron, which enhances non-heme iron absorption. Choices A and C are incorrect because vegan diets require more vitamin C, while smoking increases the need for vitamin C.

3. A nurse is providing MyPlate education to a client newly diagnosed with diabetes mellitus. Which plate chosen by the client indicates the teaching was effective, according to the MyPlate guidelines?

• A. 1/2 of the plate is filled with carbohydrate foods, 1/4 filled with protein foods, and 1/4 filled with fruits and vegetables
• B. 1/2 of the plate is filled with protein foods, 1/4 filled with carbohydrates, and 1/4 filled with non-starchy vegetables
• C. 1/2 of the plate is filled with carbohydrates, 1/4 filled with protein foods, and 1/4 filled with non-starchy vegetables
• D. 1/2 of the plate is filled with non-starchy vegetables, 1/4 filled with protein foods, and 1/4 filled with carbohydrate foods

Correct answer: D

Rationale: The correct answer is D. This option reflects the MyPlate guidelines for managing diabetes effectively. In diabetes management, it is essential to focus on non-starchy vegetables, appropriate protein portions, and controlled carbohydrate intake. Option A places too much emphasis on carbohydrates, which may not be suitable for diabetes. Option B swaps the proportions of protein and carbohydrates, which is not in line with the recommended distribution. Option C places too much emphasis on carbohydrates and lacks the emphasis on non-starchy vegetables, making it less suitable for diabetes management.

4. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone?

• A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
• B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24
• C. Have the registered nurse, family and doctor sign the order
• D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

5. What is the procedure called when direct observations are used to generate an estimate of a client's current food intake?

• A. Food diary
• B. 24-hour recall
• C. Kilocalorie count
• D. Nutrient surveillance record

Correct answer: C

Rationale: A kilocalorie count is the correct answer as it involves directly observing a client's food intake, which is often used in hospitals to accurately assess nutritional intake and ensure it meets dietary requirements. A food diary (Choice A) is typically self-reported by the client and not directly observed. A 24-hour recall (Choice B) is also usually self-reported and relies on a client's memory of the past 24 hours, which can be unreliable. A nutrient surveillance record (Choice D) is a broader term for tracking nutrient intake in a population and is not specific to the direct observation of an individual's food intake.

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