Nursing Elites

1. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

2. Which vitamin's recommended dietary allowance (RDA) is significantly increased during pregnancy?

• A. Folate
• B. Thiamine (B1)
• C. Riboflavin (B2)
• D. Niacin (B3)

Correct answer: A

Rationale: The correct answer is A: Folate. During pregnancy, the recommended dietary allowance (RDA) for folate is significantly increased to support fetal development and prevent neural tube defects and other congenital anomalies. Folate plays a crucial role in DNA synthesis and cell growth, making it essential for the rapidly dividing cells of the developing fetus. Thiamine (B1), Riboflavin (B2), and Niacin (B3) are important vitamins, but their RDAs do not undergo as significant an increase during pregnancy as folate's RDA does.

3. A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?

• A. Reduce complex carbohydrates to 30% of total calories.
• B. Restrict protein intake to less than 0.8 g/kg/day.
• C. Decrease daily caloric intake by 20%.
• D. Limit sodium to 2000 mg or less per day.

Correct answer: D

Rationale: The correct answer is to limit sodium to 2000 mg or less per day. Ascites, which is the abnormal accumulation of fluid in the abdominal cavity, is commonly associated with liver disease. Limiting sodium intake helps manage fluid retention by reducing the fluid accumulation in the abdomen. Choices A, B, and C are incorrect because reducing complex carbohydrates, restricting protein intake, or decreasing caloric intake are not the primary interventions for managing ascites in liver disease.

4. he can be expected to:

• A. Profit from vocational training with moderate supervision
• B. Live successfully in the community
• C. Perform simple tasks in closely supervised settings
• D. Acquire academic skills of 6th grade level

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.

5. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

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