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. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?

• A. Tell her family that probably she can’t hear them
• B. Talk loudly so that Wendy can hear you
• C. Tell her family who are in the room not to talk
• D. Speak softly then hold her hands gently

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.

3. What instruction should the nurse include on weight gain during pregnancy?

• A. Failure to obtain the required weight gain during pregnancy will increase the risk of preterm birth.
• B. An obese client needs to gain as much weight as a client with a normal body mass index.
• C. A client with a normal body mass index should plan on gaining 50 pounds.
• D. Clients will need to eat for two when they are pregnant.

Correct answer: A

Rationale: Appropriate weight gain is crucial for reducing the risk of preterm birth.

4. A nurse is caring for a client who is receiving parenteral nutrition. Which of the following findings indicates the therapy is effective?

• A. Client has soft, formed bowel movements.
• B. Client’s mucous membranes are pink.
• C. Client reports ability to complete ADLs.
• D. Client’s blood glucose level is within the expected reference range.

Correct answer: D

Rationale: The correct answer is D because having a blood glucose level within the expected reference range indicates that parenteral nutrition is effectively meeting the client's nutritional needs. Choices A, B, and C are incorrect because soft, formed bowel movements, pink mucous membranes, and the ability to complete activities of daily living do not directly reflect the effectiveness of parenteral nutrition therapy.

5. What is the end product of lipid digestion?

• A. fatty acid
• B. sucrose
• C. monosaccharide
• D. amino acid

Correct answer: A

Rationale: The correct answer is A, fatty acid. During the process of lipid digestion, triglycerides are broken down into fatty acids and glycerol. These end products are then absorbed into the bloodstream or lymphatic system for further processing. Choices B, C, and D are incorrect because sucrose is a disaccharide, monosaccharide is a simple sugar unit, and amino acid is a building block of proteins, not the end product of lipid digestion.

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