Nursing Elites

1. During the first 24 hours after the thermal injury, you should assess Sergio for:

• A. hypokalemia and hypernatremia
• B. hypokalemia and hyponatremia
• C. hyperkalemia and hyponatremia
• D. hyperkalemia and hypernatremia

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

2. Which vitamin is crucial for collagen synthesis and wound healing?

• A. Vitamin C
• B. Vitamin D
• C. Vitamin E
• D. Vitamin K

Correct answer: A

Rationale: The correct answer is Vitamin C. Vitamin C is crucial for collagen synthesis, a process important for wound healing. Collagen is a key protein that helps in wound repair and tissue strength. Vitamin D is primarily known for its role in calcium absorption and bone health, not directly related to collagen synthesis. Vitamin E is an antioxidant that helps protect cells from damage but is not directly involved in collagen synthesis. Vitamin K is essential for blood clotting but does not play a major role in collagen synthesis for wound healing.

3. A client with hypertension is being educated by a nurse about a heart-healthy diet. Which of the following statements indicates that the client understands the teaching?

• A. I will get 15% of my total daily calories from saturated fats.
• B. I will decrease the potassium in my diet.
• C. I will limit my daily sodium intake to 3 grams.
• D. I will eat five 8-ounce servings of fruit daily.

Correct answer: C

Rationale: The correct answer is C. Limiting daily sodium intake to 3 grams is crucial in managing blood pressure and is a fundamental aspect of a heart-healthy diet. High sodium intake can contribute to hypertension and cardiovascular issues. Choices A, B, and D are incorrect because getting 15% of daily calories from saturated fats, decreasing potassium intake, and eating five servings of fruit do not directly address the management of hypertension through sodium restriction.

4. What are sheets/forms that provide an efficient and time-saving way to record information that must be obtained repeatedly at regular and/or short intervals of time? This does not replace progress notes; instead, it records information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc. These are used whenever specific measurements or observations need to be documented repeatedly. What is this?

• A. Nursing Kardex
• B. Graphic Flow Sheets
• C. Discharge Summary
• D. Medicine and Treatment Record

Correct answer: A

Rationale: The correct answer is A, Nursing Kardex. Nursing Kardex is a tool used for documenting essential patient information that needs to be recorded repeatedly at regular intervals. It includes vital signs, intake and output, treatment details, postoperative care, postpartum care, and diabetic regimen. This tool is efficient and time-saving for healthcare professionals. Choice B, Graphic Flow Sheets, may be used for visual representation of patient data but is not specifically designed for repeated documentation of essential information. Choice C, Discharge Summary, is a document outlining the patient's care and condition at the time of discharge, not for repeated recording of ongoing data. Choice D, Medicine and Treatment Record, focuses more on specific medications and treatments rather than a comprehensive recording of various patient data needed at regular intervals.

5. Approximately 70 to 80 percent of acute pancreatitis cases are caused by gallstones or _____.

• A. infection
• B. alcohol abuse
• C. diabetes
• D. obesity

Correct answer: B

Rationale: Alcohol abuse is indeed a major cause of acute pancreatitis, along with gallstones, accounting for the majority of cases. While infections, diabetes, and obesity can also contribute to pancreatitis, they are not as prevalent as alcohol abuse and gallstones in causing acute pancreatitis.

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