Nursing Elites

1. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?

• A. Apply liberal amount of mineral oil to the area
• B. Use karaya paste and rings around the stoma
• C. Clean the area daily with soap and water before applying bag
• D. Apply talcum powder twice a day

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.

2. A patient is being cared for by a nurse who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?

• A. Serve foods without sauces or gravies
• B. Offer mouth rinses with normal saline and water
• C. Serve foods while still at a hot temperature
• D. Instruct the client to drink liquids without a straw

Correct answer: B

Rationale: Offering mouth rinses with normal saline and water is an appropriate intervention for a nurse caring for a patient with stomatitis following radiation treatment. This intervention can help soothe and clean the mouth, promoting comfort and oral hygiene. Choice A is incorrect because serving foods without sauces or gravies does not directly address the client's stomatitis. Choice C is incorrect because serving hot foods can exacerbate discomfort in the client's mouth. Choice D is incorrect because using a straw can help in preventing further irritation in the client's mouth.

3. Hypertrophic burn scars are caused by:

• A. exaggerated contraction
• B. random layering of collagen
• C. wound ischemia
• D. delayed epithelialization

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

• A. triglycerides > 150 mg/dL
• B. BMI > 31
• C. LDL cholesterol < 128 mg/dL
• D. blood pressure of 128/82 mmHg

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

5. 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.

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