Nursing Elites

1. During the acute phase of a burn, the priority nursing intervention in caring for this client is:

• A. Prevention of infection
• B. Pain management
• C. Prevention of bleeding
• D. Fluid resuscitation

Correct answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.

2. What nursing diagnosis would be most appropriate for a patient with heart failure?

• A. risk for infection
• B. fluid volume excess
• C. impaired body temperature
• D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

3. A client is being taught how to follow a low-purine diet for gout management. Which statement indicates the client understands the teaching?

• A. "I will need to limit the number of fruit servings each day."?
• B. "I should avoid eating liver and other organ meats."?
• C. "I can drink only white wine."?
• D. "I should choose red meat instead of poultry."?

Correct answer: B

Rationale: The correct answer is B. Organ meats like liver are high in purines, which can exacerbate gout symptoms. Choosing to avoid such foods is essential in following a low-purine diet. Option A is incorrect because fruits are generally low in purines and are not usually restricted in a low-purine diet. Option C is incorrect as white wine, just like other types of alcohol, should be consumed in moderation or avoided due to its purine content. Option D is incorrect because red meat, including beef and lamb, is high in purines and should be limited in a low-purine diet.

4. A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

• A. A client with a weight of 128 lb and height of 70 inches
• B. A client with a weight of 150 lb and height of 68 inches
• C. A client with a weight of 200 lb and height of 72 inches
• D. A client with a weight of 133 lb and height of 60 inches

Correct answer: A

Rationale: To determine a healthy BMI, we need to calculate it using the formula: BMI = weight (lbs) / height^2 (inches) x 703. For choice A, BMI = 128 / (70 x 70) x 703 = 18.38, which falls within the healthy BMI range of 18.5-24.9. Therefore, choice A is correct. Choices B, C, and D have BMIs of 22.8, 27.1, and 26.1, respectively, which are outside the healthy range. Thus, choices B, C, and D are incorrect.

5. What is the term for a barrier that prevents the normal emptying of stomach contents into the duodenum?

• A. Dumping syndrome
• B. Gastritis
• C. Gastric outlet obstruction
• D. Hypochlorhydria

Correct answer: C

Rationale: Gastric outlet obstruction refers to a condition where the opening between the stomach and the duodenum is blocked, preventing the normal passage of food. This is why choice 'C' is correct. 'A: Dumping syndrome' is incorrect because it is a condition where stomach contents move too quickly through the small intestine, not a barrier preventing emptying. 'B: Gastritis' is inflammation of the stomach lining, not a blockage of the outlet. 'D: Hypochlorhydria' refers to low stomach acid, which may affect digestion but does not create a physical barrier blocking the outlet of the stomach.

Similar Questions