Nursing Elites

1. A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?

• A. Keep track of calorie intake for food and beverages.
• B. Provide a low-protein, high-carbohydrate diet.
• C. Schedule meals at 6-hour intervals.
• D. Provide a high-protein, high-calorie diet.

Correct answer: D

Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.

2. A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.

3. A healthcare professional is reviewing the laboratory findings of a client who has diabetes mellitus. Which of the following findings indicates a need to revise the client's plan of care?

• A. Serum sodium 144 mEq/L.
• B. HbA1c 10%.
• C. Random serum glucose 190 mg/dL.
• D. Creatinine 1.2 mg/dL.

Correct answer: C

Rationale: Elevated random serum glucose levels of 190 mg/dL indicate hyperglycemia and poor blood sugar control, requiring a revised plan of care. HbA1c levels above 7% also indicate long-term poor control of blood sugar. Serum sodium of 144 mEq/L and creatinine of 1.2 mg/dL are within normal ranges and do not directly indicate a need for a plan of care revision.

4. A client with a new diagnosis of hypertension is being taught about lifestyle changes by a nurse. Which of the following recommendations should the nurse include?

• A. Limit sodium intake to no more than 1,500 mg per day.
• B. Exercise for at least 150 minutes each week.
• C. Avoid all dairy products.
• D. Limit intake of all carbohydrates.

Correct answer: A

Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to no more than 1,500 mg per day. This helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is a good recommendation as well, but the primary focus for hypertension management in this scenario is limiting sodium. Choices C and D are incorrect as dairy products and carbohydrates are not directly linked to hypertension.

5. A client is being taught about patient-controlled analgesia (PCA). Which statement should be included in the teaching?

• A. The PCA will deliver a double dose of medication when you push the button twice.
• B. Continuous PCA infusion is designed to allow fluctuating plasma medication levels.
• C. You should push the button before physical activity to allow maximum pain control.
• D. You can adjust the amount of pain medication you receive by pushing on the keypad.

Correct answer: D

Rationale: The correct statement to include in the teaching about PCA is that the client can adjust the amount of pain medication they receive by pushing on the keypad. This empowers the client to control their pain management effectively. Choice A is incorrect because PCA systems are programmed to prevent double dosing when the button is pressed multiple times in quick succession. Choice B is incorrect as continuous PCA infusion aims to maintain a steady plasma medication level. Choice C is incorrect because it is not necessary to push the button before physical activity to ensure maximum pain control; the client should use the PCA as needed for pain relief.

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