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. Each statement is true, except one. Which is the exception?

• A. Infant formulas should be discontinued at approximately 1 year of age
• B. Low-fat milk is not recommended for children younger than 2 years
• C. Special toddler formulas are available but are unnecessary
• D. Vitamin D-fortified whole milk should not be provided until 2 years

Correct answer: D

Rationale: The correct answer is D. Vitamin D-fortified whole milk should be provided starting at age 1 after discontinuing breast feeding or infant formulas, not at 2 years. Providing whole milk at age 2 is appropriate. Choices A, B, and C are correct statements: infant formulas are typically discontinued around 1 year of age, low-fat milk is not recommended for children under 2 years, and special toddler formulas are unnecessary.

3. In the recent technological innovations, which of the following describe researches that are made to improve and make human life easier?

• A. Pure research
• B. Basic research
• C. Applied research
• D. Experimental research

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. What level of sodium restriction would be included as part of nutrition therapy for heart failure?

• A. Less than 500 mg per day
• B. 1000 mg to 1500 mg per day
• C. 1500 mg to 3000 mg per day
• D. 3000 to 3500 mg per day

Correct answer: C

Rationale: The correct answer is 1500 mg to 3000 mg per day. This is the level of sodium restriction typically recommended for heart failure patients. It helps manage fluid retention and reduce blood pressure, which are both crucial in treating heart failure. A sodium intake of less than 500 mg per day (Choice A) might be too restrictive and is not typically recommended. Similarly, an intake of 1000 mg to 1500 mg per day (Choice B) falls short of the recommended range. Lastly, an intake of 3000 to 3500 mg per day (Choice D) exceeds the recommended upper limit, potentially exacerbating fluid retention and high blood pressure.

5. 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.

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