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.
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What is the primary food safety concern for a patient undergoing chemotherapy?
- A. Possible food allergy reactions
- B. Possible food-drug interactions
- C. Possible pesticide residue
- D. Potential risk of foodborne illness
Correct Answer: D
Rationale: The correct answer is D: Potential risk of foodborne illness. Patients undergoing chemotherapy have compromised immune systems, making them more susceptible to foodborne illnesses. Chemotherapy can reduce the count of white blood cells, which impairs the body's ability to fight off infections from bacteria or other pathogens that might be present in food. Therefore, the prevention of foodborne illnesses is a critical concern for these patients. Choices A, B, and C, while they represent valid concerns for food safety in general, are not the primary concern for patients undergoing chemotherapy. These patients are at a heightened risk of experiencing severe complications from foodborne illnesses, making it a more significant concern than potential food allergies, food-drug interactions, or pesticide residues.
What should be the next step in the nursing research process?
- A. Review related literature
- B. Seek permission from the hospital administrator
- C. Identify the research problem
- D. Develop methods for data collection
Correct Answer: D
Rationale: The correct answer is 'Develop methods for data collection' (Choice D). In the nursing research process, after the research problem has been identified, the next step would typically be to develop methods for how data will be collected. This is essential to effectively address the research problem. 'Review related literature' (Choice A), while an important step, usually occurs after the research problem has been identified and before methods for data collection are developed. 'Seek permission from the hospital administrator' (Choice B) might be necessary at some point in certain situations, but it is not the immediate next step in the research process. 'Identify the research problem' (Choice C) would typically come before developing methods for data collection. Therefore, according to the typical sequence of steps in the nursing research process, Choice D is correct.
When assessing older adult clients for malnutrition at an adult day care center, which risk factors should the nurse consider?
- A. Dental problems
- B. Depression
- C. Both A and B
- D. Ability to prepare meals
Correct Answer: C
Rationale: The correct answer is C: Both A and B. Dental problems and depression are both significant risk factors for malnutrition in older adults. Dental problems can lead to difficulty in chewing and swallowing, resulting in reduced food intake. On the other hand, depression can cause changes in appetite and decreased interest in eating, which can also contribute to malnutrition. Although the ability to prepare meals is important, it is not specifically identified as a risk factor for malnutrition within the context of this question. Therefore, choices A and B are the most appropriate answers.
A nurse is providing preventative information to a group of parents with toddlers about choking. Which food item should the nurse recommend for this age group?
- A. Banana slices
- B. Popcorn
- C. Hot dogs
- D. Carrot sticks
Correct Answer: A
Rationale: Banana slices are the most suitable food option for toddlers to prevent choking. Toddlers are at a higher risk of choking due to their small airways and developing chewing abilities. Banana slices are soft, easy to chew, and less likely to cause choking compared to other options. Popcorn and hot dogs are common choking hazards for young children due to their shape and texture. While carrot sticks may be a healthy choice, they can also pose a choking risk due to their hardness and shape. Therefore, recommending banana slices to parents of toddlers is the safest choice to prevent choking incidents, making choice 'A' the correct answer. Choices 'B', 'C', and 'D' are incorrect because they can potentially cause choking in toddlers.
Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?
- A. Position June in an upright lateral position
- B. Perform range of motion exercises
- C. Apply antiembolic stockings
- D. Use hand rolls or pillows for support
Correct Answer: C
Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.