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 intervention would be most appropriate for a patient who has difficulty eating because of chewing problems?

• A. Use squeeze bottles to pour liquids into the mouth
• B. Provide utensils that have modified handles
• C. Offer plates with food guards
• D. Provide soft foods

Correct answer: D

Rationale: Providing soft foods is crucial for patients with chewing difficulties to ensure they can consume adequate nutrition without discomfort.

3. Which vitamin is essential for proper blood clotting?

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

Correct answer: C

Rationale: Vitamin K is vital for the synthesis of clotting factors, which are necessary for proper blood clotting. Vitamin A (Choice A) is important for vision and skin health, not blood clotting. Vitamin E (Choice B) is an antioxidant that helps protect cells from damage but is not directly involved in blood clotting. Vitamin C (Choice D) is essential for collagen synthesis and a healthy immune system, but it does not play a direct role in blood clotting.

4. Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the following is the best nursing intervention to prevent future falls?

• A. Tell Angie not to get up from bed unassisted
• B. Put the call bell within her reach
• C. Put bedside commode at the bedside to prevent Angie from getting up
• D. Put the bed in the lowest position ever

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. Which adolescent student lunch, evaluated by the school nurse, is the least nutritious?

• A. Ham sandwich, apple, and milk
• B. Hamburger, fries, and soft drink
• C. Macaroni and cheese, green beans, and peaches
• D. Meatloaf, broccoli, and pear slices

Correct answer: B

Rationale: The correct answer is B: Hamburger, fries, and soft drink. This meal is considered the least nutritious among the options provided due to its high content of unhealthy fats, processed carbohydrates, and added sugars, which lack essential nutrients. On the other hand, choice A: Ham sandwich, apple, and milk, offers a balanced meal with protein, fiber, vitamins, and calcium. Choice C: Macaroni and cheese, green beans, and peaches, provides a mixture of carbohydrates, vegetables, and fruits. Choice D: Meatloaf, broccoli, and pear slices, includes protein, fiber, and vitamins. Thus, all choices except B provide a more balanced and nutritious meal.

Similar Questions