Nursing Elites

1. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

2. The component that should receive the highest priority before physical examination is the:

• A. Psychological preparation of the client
• B. Physical Preparation of the client
• C. Preparation of the Environment
• D. Preparation of the Equipments

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.

3. When conducting assessments for malnutrition, which risk factors should the nurse consider? (SATA)

• A. Dental problems
• B. Depression
• C. Ability to read and write
• D. All of the above

Correct answer: D

Rationale: When assessing for malnutrition, nurses should consider multiple risk factors. Dental problems and depression can impact a person's ability to eat and maintain proper nutrition. The ability to read and write may not directly relate to malnutrition risk. The correct answer is 'All of the above' because dental problems and depression are indeed risk factors, along with other factors like the inability to prepare meals and the loss of a spouse.

4. During nutritional counseling, what is the most important step to take?

• A. Consult the patient's family
• B. Formulate a sample diet plan before presenting it to the patient
• C. Include members of the dental team in the dietary formulation
• D. Include the patient in the formulation of the dietary plan

Correct answer: D

Rationale: During nutritional counseling, the most important step is to include the patient in the formulation of the dietary plan. This ensures their active involvement, understanding, and commitment to the plan, leading to better compliance and success in achieving nutritional goals. Consulting the patient's family (Choice A) may be helpful but should not replace involving the patient directly. Formulating a sample diet plan before presenting it to the patient (Choice B) may not align with the patient's preferences or needs. Including members of the dental team in the dietary formulation (Choice C) may not be necessary unless specific dental concerns need to be addressed.

5. A nurse is caring for a client with a major burn injury and is receiving TPN. Which of the following lab tests is the priority for the nurse to use to confirm the client is receiving adequate nutrition?

• A. Iron
• B. Magnesium
• C. Folic acid
• D. Prealbumin

Correct answer: D

Rationale: Prealbumin is a sensitive indicator of protein status and nutrition, making it a priority for assessing nutritional adequacy in clients receiving TPN. Iron, magnesium, and folic acid levels are important for overall health but do not specifically indicate nutritional adequacy in the context of TPN administration.

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