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. Bacterial growth and plaque formation are enhanced by a diet with frequent intake of retentive carbohydrates. Gingivitis is an irreversible change in the interdental papillary tissues.

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: C

Rationale: The correct answer is C. The first statement is true; retentive carbohydrates promote bacterial growth and plaque formation. However, the second statement is false; gingivitis is not irreversible and is often reversible with proper care. Gingivitis is the inflammation of the gums due to plaque buildup and poor oral hygiene. With good oral hygiene practices and professional dental care, gingivitis can be reversed. The other choices are incorrect because gingivitis is not irreversible, making statement two false.

3. What is the purpose of the cuff in a Tracheostomy tube?

• A. Separate the upper and lower airway
• B. Separate trachea from the esophagus
• C. Separate the larynx from the nasopharynx
• D. Secure the placement of the tube

Correct answer: B

Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.

4. What goal should an overweight woman include in her lifestyle for a healthy pregnancy?

• A. Aim to lose 11 to 20 pounds during pregnancy
• B. Increase protein intake to 35% of total calories
• C. Delay weight loss until after pregnancy
• D. Increase daily energy intake by 550 calories

Correct answer: C

Rationale: The healthiest approach for an overweight pregnant woman is to delay weight loss until after pregnancy. During pregnancy, the body needs sufficient nutrition and energy to support the growth and development of the baby. Attempting to lose weight during pregnancy, especially significant amounts, may compromise the health of both the mother and the baby. Increasing protein intake to 35% of total calories or energy intake by 550 calories per day without professional guidance may lead to an unbalanced diet, which is not optimal for pregnancy. The focus should be on maintaining a balanced, nutrient-rich diet and appropriate weight gain during pregnancy.

5. In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:

• A. 1 hour
• B. 5 minutes
• C. 15 minutes
• D. 30 minutes

Correct answer: A

Rationale: Correct Answer: A - Vital signs monitoring in the PACU (Post-Anesthesia Care Unit) is typically done every hour to closely monitor the patient's condition during the immediate postoperative period. This frequency allows the nurse to promptly identify any changes in the patient's vital signs and intervene as necessary. Choice B (5 minutes) is too frequent for routine vital signs monitoring in the PACU and may not allow for a comprehensive assessment of the patient's stability. Choice C (15 minutes) and Choice D (30 minutes) are also not in line with the standard practice of vital signs monitoring in the PACU, which is typically hourly.

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