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. In a patient with liver cirrhosis, weight gain due to fluid retention can mask the symptoms of what condition?

• A. Liver failure
• B. Gallbladder disease
• C. Heart failure
• D. Protein-Energy Malnutrition (PEM)

Correct answer: D

Rationale: In a patient with liver cirrhosis, weight gain due to fluid retention can mask Protein-Energy Malnutrition (PEM) symptoms. This can lead to an increase in weight, making it challenging to identify weight loss or muscle wasting associated with PEM. Therefore, option D is correct. Options A, B, and C are incorrect because fluid retention and weight gain related to liver cirrhosis do not necessarily hide the symptoms of liver failure, gallbladder disease, or heart failure.

3. Each of the following describes the physiologic roles of water, except one. Which is the exception?

• A. Acts as a solvent for chemical reactions.
• B. Maintains stability of body fluids.
• C. Enables transport of nutrients and excretion of waste.
• D. Regulates temperature by pooling as perspiration on skin.

Correct answer: D

Rationale: The correct answer is D. Water regulates body temperature by evaporating as perspiration from the skin, not by pooling. When sweat evaporates from the skin, it takes away heat, which helps cool the body. Choices A, B, and C are correct because water acts as a solvent for chemical reactions, maintains the stability of body fluids, and enables the transport of nutrients and excretion of waste, respectively.

4. 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.

5. A client is being taught by a nurse about adding more fiber to the diet. Which of the following foods has the highest fiber content?

• A. 1 cup cooked sweet potato
• B. 1 slice rye toast
• C. 1 cup raw watermelon
• D. 1 oz cashews

Correct answer: D

Rationale: The correct answer is D, 1 oz of cashews. Cashews have a higher fiber content compared to sweet potato, rye toast, and watermelon. While sweet potatoes and rye toast contain fiber, cashews have a higher concentration, making them a better choice for increasing fiber intake. Watermelon, on the other hand, is low in fiber compared to the other options provided.

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