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. Mang Caloy is scheduled to have a hemorrhoidectomy, after the operation, you would expect that the client’s position post operatively will be:

• A. Knee chest position
• B. Side lying position
• C. Sims position
• D. Genopectoral position

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. The nurse is correct in performing suctioning when she applies the suction intermittently during:

• A. Insertion of the suction catheter
• B. Withdrawing of the suction catheter
• C. both insertion and withdrawing of the suction catheter
• D. When the suction catheter tip reaches the bifurcation of the trachea

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. A client is prescribed a 1500-calorie diet. Thirty percent of the calories are to be derived from fat. How many grams of fat should the nurse tell the client to consume per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 21
• B. 49
• C. 60
• D. 50

Correct answer: D

Rationale: To calculate the grams of fat, first, determine the calories from fat by multiplying the total calorie intake (1500 calories) by the percentage of calories from fat (30%), which equals 450 calories from fat. Since 1 gram of fat is equivalent to 9 calories, divide the total calories from fat (450) by the calories in 1 gram of fat (9) to get the answer in grams, which is 50. Therefore, the client should consume 50 grams of fat per day. Choice A (21), Choice B (49), and Choice C (60) are incorrect as they do not reflect the accurate calculation based on the given information.

5. A nurse is caring for a client who is receiving parenteral nutrition. Which of the following findings indicates the therapy is effective?

• A. Client has soft, formed bowel movements.
• B. Client’s mucous membranes are pink.
• C. Client reports ability to complete ADLs.
• D. Client’s blood glucose level is within the expected reference range.

Correct answer: D

Rationale: The correct answer is D because having a blood glucose level within the expected reference range indicates that parenteral nutrition is effectively meeting the client's nutritional needs. Choices A, B, and C are incorrect because soft, formed bowel movements, pink mucous membranes, and the ability to complete activities of daily living do not directly reflect the effectiveness of parenteral nutrition therapy.

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