Nursing Elites

1. A client who is postoperative following a liver transplant and weighs 65 kg. Which of the following actions should the nurse plan to take?

• A. Keep the client NPO for the first week postoperative.
• B. Limit caloric content once the client resumes eating.
• C. Stress the importance of safe food-handling practices.
• D. Decrease foods high in carbohydrates once the client resumes eating.

Correct answer: C

Rationale: After a liver transplant, it is crucial to stress the importance of safe food-handling practices to prevent foodborne illnesses, especially due to the client's altered immune system. Keeping the client NPO for the first week postoperative is not recommended as early nutrition support is essential for recovery. Limiting caloric content once the client resumes eating may not be appropriate as they need adequate nutrition for healing. Decreasing foods high in carbohydrates without a specific indication may lead to inadequate nutrient intake, which is not ideal for the client's recovery.

2. Which of the following statements about Z-Track technique is false?

• A. Z-Track injections prevent irritation of the subcutaneous tissues
• B. The technique involves creating a Zig-Zag like pattern of medication
• C. It forces the medication to be contained in the subcutaneous tissues
• D. It is used when administering Parenteral Iron

Correct answer: B

Rationale: The Z-Track technique is aimed at preventing medication leakage into the surrounding tissues by sealing the medication in the muscle, not by creating a Zig-Zag pattern. Choice A is correct as Z-Track injections help prevent irritation. Choice C is correct as it accurately describes how the technique works. Choice D is also correct as the Z-Track technique is commonly used when administering Parenteral Iron to prevent staining and irritation of the surrounding tissues.

3. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

4. What characterizes Obsessive Compulsive Disorder?

• A. Uncontrollable impulse to perform an act or ritual repeatedly
• B. Persistent thoughts and behavior
• C. Recurring unwanted and disturbing thoughts
• D. Pathological persistence of unwilled thoughts

Correct answer: A

Rationale: Obsessive Compulsive Disorder (OCD) is characterized by the uncontrollable impulse to perform an act or ritual repeatedly (Choice A). This is driven by recurring unwanted and disturbing thoughts (Choice C), but the distinguishing factor is the compulsive behavior, making choice A the most accurate. While choice B can be seen as true, it lacks the specific detail of the compulsive behavior that makes A a better answer. Choice D is not incorrect, but it uses terminology that is less precise and less commonly used to describe OCD, making it a less accurate choice than A. The provided rationale is not relevant to the question.

5. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” is an example of:

• A. Delusion of grandeur
• B. Visual Hallucination
• C. Religious delusion
• D. Auditory Hallcucination

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.

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