Nursing Elites

1. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

2. A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?

• A. Stabilize the tube with tape to the newborn’s cheek.
• B. Remove supplemental oxygen during the feeding.
• C. Measure the stomach aspirate prior to the feeding.
• D. Place the newborn on their left side for 30 minutes after the feeding.

Correct answer: C

Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn’s cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.

3. Which is NOT a prudent recommendation for a menopausal patient?

• A. Supplement calcium and vitamin D slightly beyond upper intake level
• B. Encourage lean protein and regular exercise
• C. Avoid alcohol if xerostomia is present
• D. Consumption of 90 mg daily of isoflavones in soy products helps to increase bone mass

Correct answer: A

Rationale: Excessive supplementation of calcium and vitamin D beyond the upper intake level is not recommended unless under medical supervision, as it can cause adverse health effects.

4. What dietary factor raises triglyceride levels?

• A. high refined carbohydrate intake
• B. low soluble fiber intake
• C. high iron intake
• D. low fat intake

Correct answer: A

Rationale: The correct answer is A: high refined carbohydrate intake. High intake of refined carbohydrates, such as sugars and white flour, can lead to elevated triglyceride levels, increasing the risk of cardiovascular disease. Choice B, low soluble fiber intake, is incorrect because soluble fiber actually helps lower triglyceride levels. Choice C, high iron intake, is incorrect as iron intake is not directly linked to raising triglyceride levels. Choice D, low fat intake, is also incorrect as not all fats raise triglyceride levels; it depends on the type of fat consumed.

5. How many grams of protein per day are recommended for a person weighing 150 lbs?

• A. 120
• B. 85
• C. 187.5
• D. 54

Correct answer: D

Rationale: The Recommended Dietary Allowance (RDA) for protein is 0.8 grams per kilogram of body weight. To convert pounds to kilograms, divide the weight in pounds by 2.2. Therefore, a 150 lb person weighs approximately 68 kg (150 / 2.2 = 68). Multiplying 68 kg by 0.8 grams gives us 54 grams of protein per day. Choices A, B, and C are incorrect as they do not align with the RDA calculation based on body weight.

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