Nursing Elites

1. 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.

2. Which of the following are examples of mechanical digestion? Select all that apply.

• A. Heat
• B. Segmentation
• C. Option B and D
• D. Peristalsis

Correct answer: C

Rationale: Mechanical digestion involves physical movements that break down food in the digestive tract. Segmentation (choice B) and peristalsis (choice D), which are both movements of the muscles in the digestive tract, are examples of this type of digestion. Heat (choice A), on the other hand, is related to chemical digestion, not mechanical digestion. Therefore, choice C (Option B and D) is the correct answer as it includes both examples of mechanical digestion provided in the choices. Choices A and D are incorrect because heat (choice A) is not a mechanical digestion process, and peristalsis (choice D) is a movement that helps propel food along the digestive tract but is not directly involved in breaking down food physically.

3. A factor contributing to the risk for dehydration in the older adult is that _____.

• A. drinking fluids causes loss of bladder control
• B. older adults do not seem to notice mouth dryness as readily as younger people
• C. increased fluid intake will decrease the intake of nutrient-dense foods
• D. changes in intestinal motility contribute to excess fluid loss

Correct answer: C

Rationale: Older adults may not notice mouth dryness as readily as younger individuals, increasing their risk for dehydration, especially if they do not consciously increase fluid intake.

4. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone?

• A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
• B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24
• C. Have the registered nurse, family and doctor sign the order
• D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

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 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.

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