Nursing Elites

1. Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is the child of the covenant that would save this world from the evil forces of Satan. One morning, while caring for her, she stood in front of you and said “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” The best response by the Nurse is:

• A. Tell me more about being the Virgin Mary
• B. So, You are the Virgin Mary?
• C. Excuse me but, you are not anymore a Virgin so you cannot be the Blessed Virgin Mary.
• D. You are Maria Salvacion

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.

2. 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.

3. A nurse is planning teaching for the parents of a toddler who follows a vegetarian diet. The nurse should plan to include which of the following foods as the best source of dietary protein for the child?

• A. Soy milk
• B. Peanut butter
• C. Dried beans
• D. Whole grains

Correct answer: C

Rationale: Dried beans are the best source of dietary protein for a toddler following a vegetarian diet. They are rich in protein and other essential nutrients. Soy milk, while a good source of protein, may not provide as much protein density as dried beans. Peanut butter is a good source of protein but may not be as protein-dense as dried beans. Whole grains are not as high in protein content compared to dried beans, making them a less optimal choice for meeting the toddler's protein needs.

4. Proteolytic enzymes are most likely to break down which food type?

• A. Carbohydrates
• B. Proteins
• C. Fats
• D. Lipids

Correct answer: B

Rationale: Proteolytic enzymes target proteins for breakdown into amino acids. Carbohydrates are broken down by enzymes like amylase, while fats are broken down by lipase. Lipids, which include fats, are not specifically targeted by proteolytic enzymes.

5. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:

• A. perfusion
• B. locomotion
• C. respiration
• D. mentation

Correct answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

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