Nursing Elites

1. All of the following are contraindications when giving Immunization except:

• A. BCG Vaccine can be given to a child with AIDS
• B. BCG Vaccine can be given to a child with Hepatitis B
• C. DPT can be given to a child that had convulsion 3 days after being given the first DPT dose
• D. DPT can be given to a child with active convulsion or other neurological disease

Correct answer: B

Rationale: The correct answer is B. BCG vaccine can be given to a child with Hepatitis B, as there is no contraindication for this. Choice A, C, and D all present contraindications for administering immunizations. Choice A is incorrect because giving BCG vaccines to a child with AIDS is a contraindication. Choice C is incorrect as convulsions after the first DPT dose indicate a contraindication to subsequent doses. Choice D is incorrect because active convulsions or other neurological diseases are contraindications to receiving the DPT vaccine.

2. A patient has begun taking furosemide to manage heart failure. What food should the nurse recommend that the patient consume frequently while taking this drug?

• A. legumes
• B. cabbage
• C. peanut butter
• D. bananas

Correct answer: D

Rationale: Furosemide is a diuretic that can lead to potassium loss; therefore, it is recommended that patients consume potassium-rich foods like bananas to prevent hypokalemia.

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. Which nutrient is most important for wound healing in a patient post-surgery?

• A. Vitamin C
• B. Protein
• C. Iron
• D. Calcium

Correct answer: B

Rationale: Protein is essential for tissue repair and wound healing.

5. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

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