Nursing Elites

1. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

2. The nurse is working with a patient who recently had a stroke. The patient frequently chokes and coughs when eating and is having difficulty feeding herself. What is the best way to ensure adequate nutrition?

• A. to have an aide feed her at each meal
• B. to ask a family member to assist during meals
• C. to provide tube feedings for the patient
• D. to initiate TPN for the patient

Correct answer: C

Rationale: The best way to ensure adequate nutrition for a stroke patient who frequently chokes and coughs when eating and has difficulty feeding herself is to provide tube feedings. Tube feedings are a safe and effective method to deliver nutrition directly to the stomach or intestines, bypassing the swallowing mechanism, reducing the risk of aspiration. Having an aide feed her each meal (choice A) may not address the underlying issue of swallowing difficulty and aspiration risk. Asking a family member to be present at each meal (choice B) does not provide a definitive solution to the patient's nutritional needs. Placing the patient on total parenteral nutrition (TPN) (choice D) is a more invasive and typically reserved for patients who cannot tolerate enteral feedings or have non-functional gastrointestinal tracts.

3. A nurse is developing a program about strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select one that does not apply).

• A. Keep cold food temperatures below 4.4�C (40�F).
• B. Reheat leftovers before eating.
• C. Wash raw vegetables thoroughly in clean water.
• D. Keep cooked foods at 48.9�C (120�F).

Correct answer: D

Rationale: The correct answer is to keep cooked foods at 48.9�C (120�F). This temperature is too low to keep cooked foods safe from bacterial growth. The ideal temperature to keep cooked foods safe is above 60�C (140�F). Choices A, B, and C are all important strategies to prevent foodborne illnesses. Keeping cold food temperatures below 4.4�C (40�F) helps prevent bacterial growth, reheating leftovers before eating kills any bacteria that may have grown during storage, and washing raw vegetables thoroughly in clean water helps remove dirt and bacteria.

4. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet?

• A. Peanut butter and jelly sandwich
• B. Baked potato topped with sour cream
• C. Bagel with cream cheese
• D. Fruit salad

Correct answer: D

Rationale: The correct answer is 'Fruit salad.' Since the adolescent client is a vegetarian who eats milk products but does not like beans, suggesting a fruit salad for lunch would provide essential nutrients like vitamins, minerals, and fiber that are commonly found in fruits. Fruit salad can help supplement the nutrients that may be lacking in his diet. Choices A, B, and C do not offer the same variety and quantity of nutrients as a fruit salad, making them less optimal choices for meeting the client's dietary needs.

5. A Hazard Analysis and Critical Control Points (HACCP) program would address which element of food service?

• A. cleaning and disinfecting of utensils
• B. developing healthy menus
• C. controlling patient calorie intake
• D. prescribing diets for patients with swallowing problems

Correct answer: A

Rationale: The correct answer is A. Hazard Analysis and Critical Control Points (HACCP) programs are designed to ensure food safety by identifying and controlling potential hazards. This includes addressing the cleaning and disinfecting of utensils to prevent contamination and maintain safe food handling practices. Choices B, C, and D are incorrect because HACCP primarily focuses on preventing food safety hazards rather than developing menus, controlling calorie intake, or prescribing diets for specific medical conditions.

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