Nursing Elites

1. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:

• A. perfusion
• B. locomotion
• C. respiration
• D. mentation

Correct answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

2. Which change during pregnancy is related to the slowing of the gastrointestinal tract?

• A. Diarrhea
• B. Constipation
• C. Decreased absorption of iron
• D. Decreased absorption of calcium

Correct answer: B

Rationale: During pregnancy, the gastrointestinal tract tends to slow down, leading to constipation. This is due to hormonal changes that relax the intestinal muscles, allowing more time for nutrient absorption and ultimately leading to constipation. Diarrhea is not typically associated with the slowing of the gastrointestinal tract during pregnancy. Decreased absorption of iron and calcium may occur during pregnancy due to increased demands, but they are not directly related to the slowing of the gastrointestinal tract.

3. You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first?

• A. Make an incident report
• B. Call security to report the incident
• C. Wait for 2 hours before reporting
• D. Report the incident to your supervisor

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.

4. The nurse knows that the most common complication of Measles is: A Pneumonia and larynigotracheitis

• A. Encephalitis
• B. Otitis Media
• C. Bronchiectasis
• D.

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. A client with pre-dialysis end-stage kidney disease is being taught about diet. Which of the following instructions should the nurse include?

• A. Increase intake of dietary phosphorus.
• B. Eliminate foods high in protein from your diet.
• C. Reduce intake of foods high in potassium.
• D. Increase intake of sodium-containing foods.

Correct answer: C

Rationale: In pre-dialysis end-stage kidney disease, reducing intake of foods high in potassium is crucial as impaired kidney function can lead to potassium buildup in the blood, which can be dangerous. High potassium levels can cause irregular heartbeats and even cardiac arrest. Therefore, advising the client to reduce potassium-rich foods is essential to prevent complications. Choices A, B, and D are incorrect. Increasing dietary phosphorus, eliminating foods high in protein, or increasing sodium-containing foods are not appropriate recommendations for a client with pre-dialysis end-stage kidney disease as they can exacerbate the condition.

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