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. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

• A. Lubricates the tip of the catheter prior to inserting into the stoma
• B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
• C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
• D. Clamps of the flow of fluid when felling uncomfortable

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. What type of drug would most likely be given to a patient following a myocardial infarction?

• A. antiemetic
• B. anticoagulant
• C. anticonvulsant
• D. antibiotic

Correct answer: B

Rationale: Anticoagulants are the most suitable choice for a patient following a myocardial infarction. These medications are essential in preventing further blood clots from forming in the arteries, reducing the risk of complications such as strokes or recurrent heart attacks. Antiemetics are used to control nausea and vomiting, not directly related to myocardial infarction. Anticonvulsants are used to manage seizures, not typically indicated after a heart attack. Antibiotics are prescribed to treat bacterial infections, not routinely given after a myocardial infarction.

4. What is the best dietary advice for a patient with iron-deficiency anemia?

• A. Increase dairy consumption
• B. Increase vitamin C intake
• C. Reduce red meat consumption
• D. Increase fiber intake

Correct answer: B

Rationale: The best dietary advice for a patient with iron-deficiency anemia is to increase vitamin C intake. Vitamin C enhances the absorption of non-heme iron, which can help improve iron-deficiency anemia. Choices A, C, and D are not the best options for this condition. Increasing dairy consumption (Choice A) may not directly address the iron deficiency. Reducing red meat consumption (Choice C) may limit heme iron intake, which is easily absorbed by the body. Increasing fiber intake (Choice D) is generally beneficial but is not specifically recommended as the top advice for iron-deficiency anemia.

5. What is the purpose of the cuff in a Tracheostomy tube?

• A. Separate the upper and lower airway
• B. Separate trachea from the esophagus
• C. Separate the larynx from the nasopharynx
• D. Secure the placement of the tube

Correct answer: B

Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.

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