Nursing Elites

1. A client is being taught about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?

• A. Liver
• B. Milk
• C. BEANS
• D. Eggs

Correct answer: C

Rationale: Choosing beans as a food option indicates that the client understands the low-cholesterol diet instructions. Beans are a good source of fiber and plant-based protein, which can help lower cholesterol levels. On the other hand, liver and eggs are high in cholesterol and should be limited in a low-cholesterol diet. Milk, especially whole milk, can also be high in saturated fats and cholesterol, so it is not the best choice for a low-cholesterol diet.

2. When taking a blood pressure reading, where should the cuff be positioned?

• A. The cuff should be deflated fully before immediately starting a second reading for the same patient
• B. The cuff should be deflated quickly after being inflated to 180 mmHg
• C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
• D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery

Correct answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

3. A patient is being cared for by a nurse who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?

• A. Serve foods without sauces or gravies
• B. Offer mouth rinses with normal saline and water
• C. Serve foods while still at a hot temperature
• D. Instruct the client to drink liquids without a straw

Correct answer: B

Rationale: Offering mouth rinses with normal saline and water is an appropriate intervention for a nurse caring for a patient with stomatitis following radiation treatment. This intervention can help soothe and clean the mouth, promoting comfort and oral hygiene. Choice A is incorrect because serving foods without sauces or gravies does not directly address the client's stomatitis. Choice C is incorrect because serving hot foods can exacerbate discomfort in the client's mouth. Choice D is incorrect because using a straw can help in preventing further irritation in the client's mouth.

4. After consuming a meal high in fat, the _____ releases _______ to aid in digestion.

• A. stomach, acid
• B. liver, bile
• C. pancreas, bicarbonate
• D. gallbladder, bile

Correct answer: D

Rationale: The gallbladder releases bile into the small intestine to help digest fats. Bile emulsifies fats, breaking them down into smaller droplets for easier digestion. The stomach primarily releases gastric acid, the liver produces bile but stores it in the gallbladder, and the pancreas secretes bicarbonate to neutralize stomach acid in the small intestine. Therefore, choices A, B, and C are incorrect.

5. The nurse is working with a patient who recently had a stroke. The patient frequently chokes and coughs when eating and is having difficulty feeding herself. What is the best way to ensure adequate nutrition?

• A. to have an aide feed her at each meal
• B. to ask a family member to assist during meals
• C. to provide tube feedings for the patient
• D. to initiate TPN for the patient

Correct answer: C

Rationale: The best way to ensure adequate nutrition for a stroke patient who frequently chokes and coughs when eating and has difficulty feeding herself is to provide tube feedings. Tube feedings are a safe and effective method to deliver nutrition directly to the stomach or intestines, bypassing the swallowing mechanism, reducing the risk of aspiration. Having an aide feed her each meal (choice A) may not address the underlying issue of swallowing difficulty and aspiration risk. Asking a family member to be present at each meal (choice B) does not provide a definitive solution to the patient's nutritional needs. Placing the patient on total parenteral nutrition (TPN) (choice D) is a more invasive and typically reserved for patients who cannot tolerate enteral feedings or have non-functional gastrointestinal tracts.

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