Nursing Elites

1. During the detoxification stage, it is a priority for the nurse to:

• A. teach skills to recognize and respond to health threatening situations
• B. increase the client’s awareness of unsatisfactory protective behaviors
• C. implement behavior modification
• D. promote homeostasis and minimize the client’s withdrawal symptoms

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.

2. Which type of bread, cereal, or pasta would most likely be recommended for a patient on a fat-restricted diet?

• A. popcorn
• B. fried rice
• C. English muffins
• D. granola

Correct answer: C

Rationale: English muffins would be the most suitable option for a patient on a fat-restricted diet. They are typically lower in fat compared to fried rice, granola, and popcorn with butter. Popcorn, fried rice, and granola are higher in fat content and may not be the best choice for individuals on a fat-restricted diet.

3. What information should a working mother who wants to continue breastfeeding her infant by occasionally pumping milk ahead of time be given to help her successfully maintain breastfeeding?

• A. Breast milk can be refrigerated for up to 4 days
• B. Breast milk stored in a deep freezer can be kept for up to 12 months
• C. Heating breast milk in the microwave can degrade its nutritional quality
• D. Breast milk can be expressed either by hand or with an electric pump

Correct answer: D

Rationale: The correct answer is D. This information is crucial as it informs the mother of her options for expressing milk, which is the first step in being able to store and later feed it to her child while she's away at work. Choice A has been corrected to state that breast milk can be refrigerated for up to 4 days, providing a more accurate storage timeframe. Choice B has been revised to indicate that breast milk stored in a deep freezer can be kept for up to 12 months, aligning with the recommended storage duration. Choice C now highlights that heating breast milk in the microwave can degrade its nutritional quality, emphasizing the importance of using proper methods for warming breast milk and avoiding potential harm to the baby's health and well-being.

4. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

• A. Stay with the client for the first 15 minutes of blood administration
• B. Stay with the client for the entire period of blood administration
• C. Run the infusion at a faster rate during the first 15 minutes
• D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

5. Why is a pulse oximeter attached to Mr. Dizon's finger?

• A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
• B. To check the level of the patient's tissue perfusion
• C. To measure the effectiveness of the patient's anti-hypertensive medications
• D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop

Correct answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.

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