Nursing Elites

1. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

2. A nurse is instructing teenage girls on the importance of adequate calcium intake throughout their life span to prevent complications. Which complication should the nurse include in the teaching?

• A. Goiter
• B. Osteoporosis
• C. Heart disease
• D. Dental caries

Correct answer: B

Rationale: The correct answer is B: Osteoporosis. Adequate calcium intake throughout life helps prevent osteoporosis, a condition characterized by weak and brittle bones, which is common in older adults. Goiter is caused by an iodine deficiency, not calcium. Heart disease is more related to factors like cholesterol and blood pressure. Dental caries are primarily influenced by oral hygiene and sugar intake, not just calcium.

3. Which vitamin is primarily obtained from sunlight exposure?

• A. Vitamin A
• B. Vitamin C
• C. Vitamin D
• D. Vitamin E

Correct answer: C

Rationale: The correct answer is Vitamin D. Vitamin D is synthesized in the skin when it is exposed to sunlight. This process allows the body to produce Vitamin D naturally. Vitamin A (Choice A) is found in foods like liver and carrots and is not primarily obtained from sunlight. Vitamin C (Choice B) is commonly found in fruits and vegetables. Vitamin E (Choice D) is present in foods like nuts and seeds and is not primarily obtained from sunlight.

4. When conducting assessments for malnutrition, which risk factors should the nurse consider? (SATA)

• A. Dental problems
• B. Depression
• C. Ability to read and write
• D. All of the above

Correct answer: D

Rationale: When assessing for malnutrition, nurses should consider multiple risk factors. Dental problems and depression can impact a person's ability to eat and maintain proper nutrition. The ability to read and write may not directly relate to malnutrition risk. The correct answer is 'All of the above' because dental problems and depression are indeed risk factors, along with other factors like the inability to prepare meals and the loss of a spouse.

5. When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:

• A. Color, amount and consistency of sputum
• B. Character of breath sounds and respiratory rate before and after procedure
• C. Amount of fluid intake of client before and after the procedure
• D. Significant changes in vital signs

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.

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