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 chronic kidney disease is being taught about dietary needs by a nurse. Which of the following foods should the nurse identify as being the lowest in phosphorus?

• A. Medium apple
• B. Bran cereal
• C. Scrambled eggs
• D. Ground turkey

Correct answer: A

Rationale: The correct answer is A, a medium apple. Apples are a suitable option for clients with chronic kidney disease as they are low in phosphorus. Bran cereal (choice B), scrambled eggs (choice C), and ground turkey (choice D) are all higher in phosphorus content compared to apples, making them less ideal choices for individuals with chronic kidney disease.

3. During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?

• A. Discuss nutritional requirements with the client.
• B. Refer the client to a senior citizen center.
• C. Arrange for a home-delivered meal program.
• D. Perform a nutrition screening.

Correct answer: D

Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.

4. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

5. Electrolytes create _____, which is caused by water following electrolytes within or between cells.

• A. energy
• B. active transport
• C. passive diffusion
• D. osmotic pressure

Correct answer: D

Rationale: Osmotic pressure is the force that drives water movement across cell membranes due to the presence of electrolytes, helping to balance fluid levels in the body. Choice A, 'energy,' is incorrect as electrolytes do not directly create energy. Choice B, 'active transport,' refers to the movement of molecules across a cell membrane requiring energy, not the movement of water. Choice C, 'passive diffusion,' is the process by which substances move from an area of higher concentration to lower concentration, not related to the movement of water following electrolytes.

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