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. A client with cirrhosis and ascites is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Decrease the client's fluid intake.
• B. Increase the client's saturated fat intake.
• C. Increase the client's sodium intake.
• D. Decrease the client's carbohydrate intake.

Correct answer: D

Rationale: In a client with cirrhosis and ascites, decreasing carbohydrate intake is essential as it helps reduce the production of ascitic fluid. Excess carbohydrates can lead to fluid retention. Choices A, B, and C are incorrect. Decreasing fluid intake can worsen dehydration, increasing saturated fat intake is not recommended due to its impact on liver health, and increasing sodium intake can worsen fluid retention and exacerbate ascites in these clients.

3. When taking a blood pressure reading, where should the cuff be positioned?

• A. The cuff should be deflated fully before immediately starting a second reading for the same patient
• B. The cuff should be deflated quickly after being inflated to 180 mmHg
• C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
• D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery

Correct answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

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. A nurse is planning a menu for a client with a folic acid deficiency anemia. Which food should the nurse recommend that is high in folate?

• A. 4 slices of roast beef
• B. ½ cup of asparagus
• C. 1 cup part-skim mozzarella cheese
• D. ¼ cup of olives

Correct answer: B

Rationale: The correct answer is B: ½ cup of asparagus. Asparagus is high in folate, making it a suitable recommendation for clients with folic acid deficiency anemia. Folate is essential in the production of red blood cells, which is crucial in managing anemia. Choices A, C, and D do not contain as much folate as asparagus and are not the best options for addressing a folic acid deficiency anemia.

Similar Questions