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. 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.

3. Which of the following groups of vitamins are fat-soluble?

• A. vitamins B and C
• B. vitamins A and C
• C. vitamins B, E, K, D
• D. vitamins A, E, K, D

Correct answer: D

Rationale: The correct answer is D: vitamins A, E, K, and D. Fat-soluble vitamins are absorbed along with fats in the diet and can be stored in the body's fatty tissue. Vitamins B and C are water-soluble vitamins and are not stored in the body; any excess amounts are usually excreted in the urine. Therefore, choices A, B, and C are incorrect.

4. Dental hygienists are in a key position to assess and detect signs and symptoms of systemic disease because more than one third of the patients treated in a dental office frequently do not interact with a general health care provider.

• A. Both the statement and the reason are correct and related
• B. Both the statement and the reason are correct but are not related
• C. The statement is correct, but the reason is not correct
• D. The statement is not correct, but the reason is correct

Correct answer: A

Rationale: Dental hygienists often see patients more regularly than general healthcare providers, allowing them to identify systemic issues early.

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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