Nursing Elites

1. An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.

• A. Normal Saline
• B. Lactated Ringer’s
• C. 5% Dextrose in water
• D. 0.45% Sodium Chloride

Correct answer: B

Rationale: In burn patients, Lactated Ringer's solution is preferred over other options as it helps in restoring fluid and electrolyte balance effectively. Lactated Ringer's contains electrolytes (sodium, potassium, calcium) that closely mimic the body's natural composition, making it a suitable choice for fluid resuscitation in burn injuries. Normal Saline (Choice A) lacks electrolytes like potassium and calcium, which are essential in burn management. 5% Dextrose in water (Choice C) is a hypotonic solution and is not the ideal choice for fluid resuscitation in burn patients. 0.45% Sodium Chloride (Choice D) is a hypotonic solution mainly used for conditions requiring free water replacement rather than volume expansion needed in burn injuries.

2. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client’s admitting diagnosis?

• A. Jugular vein distention.
• B. Crackles in the lung bases.
• C. Peripheral edema.
• D. Bounding peripheral pulses.

Correct answer: B

Rationale: The correct answer is B: Crackles in the lung bases. Crackles in the lung bases are indicative of pulmonary congestion, which is a classic sign of left-sided heart failure. Left-sided heart failure leads to a backup of blood into the lungs, causing fluid leakage into the alveoli and resulting in crackles upon auscultation. Choices A, C, and D are less specific to left-sided heart failure. Jugular vein distention can be seen in right-sided heart failure, peripheral edema can be seen in both right and left-sided heart failure, and bounding peripheral pulses are more indicative of conditions like hyperthyroidism or anemia rather than specifically supporting left-sided heart failure.

3. When is the best time to administer pancreatic enzyme replacement?

• A. Before meals and snacks
• B. Before bedtime
• C. Early in the morning
• D. After meals and snacks

Correct answer: A

Rationale: The correct answer is to administer pancreatic enzyme replacement before meals and snacks. This timing is crucial as it allows the enzymes to assist in the digestion of carbohydrates, fats, and proteins that are consumed during the meals. Administering the replacement after meals and snacks would not be effective as the enzymes need to be present in the digestive system when food is consumed. Options B and C are incorrect as they do not align with the optimal timing for pancreatic enzyme replacement administration.

4. A client with chronic heart failure is being discharged with a new prescription for furosemide. Which instruction should the nurse include in the discharge teaching?

• A. Increase your intake of potassium-rich foods.
• B. Restrict your fluid intake to 1 liter per day.
• C. Avoid salt substitutes containing potassium.
• D. Weigh yourself once a week.

Correct answer: A

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss due to increased urinary excretion. Potassium-rich foods can help prevent hypokalemia, a potential side effect of furosemide. Restricting fluid intake (choice B) may not be suitable for all patients with heart failure, and a general restriction of 1 liter per day is not typically recommended. Avoiding salt substitutes containing potassium (choice C) is not a priority teaching point in this scenario. Weighing oneself once a week (choice D) is important for monitoring fluid status, but increasing potassium-rich foods is more directly related to the potential side effects of furosemide.

5. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?

• A. Assist with referral to specialized education.
• B. Support the child with independent toileting.
• C. Assist the child to develop effective communication.
• D. Encourage the child to ambulate independently.

Correct answer: C

Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.

Similar Questions