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. After ileostomy, which of the following condition is NOT expected?

• A. Increased weight
• B. Irritation of skin around the stoma
• C. Liquid stool
• D. Establishment of regular bowel movement

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.

3. A nurse is discussing denture care with the partner of a client who is unable to perform oral hygiene. Which of the following should be included in the discussion?

• A. Floss dentures as part of daily cleaning.
• B. Wipe dentures before storing them in a dry container at night.
• C. Wrap gloved fingers with gauze to remove dentures.
• D. Use a washcloth to clean the denture surfaces.

Correct answer: C

Rationale: The correct answer is C: 'Wrap gloved fingers with gauze to remove dentures.' This method provides a safe and effective way to remove dentures without causing damage. Choice A is incorrect because flossing dentures is not recommended. Choice B is incorrect as it suggests wiping dentures and storing them dry, which is not the best practice. Choice D is incorrect because using a washcloth may not effectively clean all denture surfaces.

4. A nurse is teaching a client about complete and incomplete proteins. Which of the following foods should the nurse include in the teaching as an incomplete protein?

• A. 4 oz chickpeas
• B. 2 poached eggs
• C. 2 oz cheddar cheese
• D. 4 oz salmon fillet

Correct answer: A

Rationale: The correct answer is A: 4 oz chickpeas. Chickpeas are considered an incomplete protein because they lack one or more essential amino acids required by the body. Incomplete proteins do not provide all essential amino acids in sufficient quantities. Choice B, 2 poached eggs, is a complete protein source because eggs contain all essential amino acids. Choice C, 2 oz cheddar cheese, is also a complete protein as it contains all essential amino acids. Choice D, 4 oz salmon fillet, is another complete protein source as fish typically provide all essential amino acids needed by the body.

5. A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?

• A. Stabilize the tube with tape to the newborn’s cheek.
• B. Remove supplemental oxygen during the feeding.
• C. Measure the stomach aspirate prior to the feeding.
• D. Place the newborn on their left side for 30 minutes after the feeding.

Correct answer: C

Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn’s cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.

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