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 has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?

• A. Replace the bag and tubing every 24 hours
• B. Flush the tubing with 10 mL water every 6 hours
• C. Administer the feeding by gravity drip
• D. Heat the formula prior to infusion

Correct answer: B

Rationale: To prevent clogging when using high-viscosity formulas in a small-bore jejunostomy, the nurse should flush the tubing with 10 mL of water every 6 hours. This action helps maintain tube patency and prevent blockages. Replacing the bag and tubing every 24 hours (Choice A) is unnecessary and does not specifically address preventing clogging. Administering the feeding by gravity drip (Choice C) or heating the formula prior to infusion (Choice D) are not effective interventions for preventing tubing clogging.

3. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is?

• A. These are statements that describe the maximum or highest level of acceptable performance in nursing practice
• B. It refers to the scope of nursing practice as defined in Republic Act 9173
• C. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing
• D. The Standards of Care includes the various steps of the nursing process and the standards of professional

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.

4. A pregnant woman has applied to use WIC services to supplement her food intake. The WIC program would provide vouchers for _____ in this situation.

• A. lean beef
• B. fruit-flavored yogurt
• C. whole grain bread
• D. refried beans

Correct answer: C

Rationale: The correct answer is C: whole grain bread. The WIC program aims to provide nutritious foods to support a healthy diet during pregnancy. Whole grain bread is a good source of fiber and essential nutrients. Choice A, lean beef, is a protein source but may not be as versatile as whole grain bread in providing a variety of nutrients essential during pregnancy. Choice B, fruit-flavored yogurt, may contain added sugars and may not offer the same level of essential nutrients as whole grain bread. Choice D, refried beans, is a good source of protein and fiber, but whole grain bread is often a staple recommended in pregnancy for its nutritional benefits.

5. A nurse is providing nutritional information to a client with osteoporosis. Which food should the nurse recommend as being the highest in calcium?

• A. 1 cup carrot strips
• B. 3 oz canned salmon
• C. 1 plain baked potato
• D. 1 cup chopped chicken breast

Correct answer: B

Rationale: Canned salmon with bones is high in calcium.

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