Nursing Elites

1. When caring for a patient with a burn injury, what is the priority intervention?

• A. Monitor the burn area for infection
• B. Administer IV fluids
• C. Debride the burn area
• D. Apply a dry dressing

Correct answer: A

Rationale: The priority intervention when caring for a patient with a burn injury is to monitor the burn area for infection. This is crucial to prevent further complications such as sepsis. While administering IV fluids is important for fluid resuscitation, it is not the top priority compared to preventing infection. Debriding the burn area and applying a dry dressing are necessary interventions for wound care, but ensuring there is no infection takes precedence to avoid sepsis and other serious complications.

2. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?

• A. Eat three large meals daily
• B. Consume high-calorie foods
• C. Limit caffeinated drinks to two per day
• D. Drink fluids during meal time

Correct answer: B

Rationale: The correct answer is B: 'Consume high-calorie foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach putting pressure on the diaphragm. Choice C is incorrect because caffeinated drinks can contribute to dehydration, which is not ideal for clients with COPD. Choice D is incorrect because drinking fluids during mealtime can cause bloating and early satiety, making it difficult for clients to consume enough calories.

3. What lab value should be prioritized for monitoring in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring CD4 T-cell count is crucial in patients with HIV as it reflects the status of their immune system. A CD4 count below 200 cells/mm3 is indicative of severe immunocompromise, necessitating close monitoring and potential intervention. Choices B, C, and D are less specific to HIV management and do not directly reflect the immune status in these patients. Hemoglobin levels are more relevant for assessing anemia, serum albumin levels for nutritional status, and white blood cell count for overall immune response, but none are as directly tied to HIV disease progression as the CD4 T-cell count.

4. What is the first medication to give to a patient experiencing wheezing due to an allergic reaction?

• A. Albuterol via nebulizer
• B. Cromolyn 20 mg via nebulizer
• C. Methylprednisolone 100 mg IV
• D. Aminophylline 500 mg IV

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction due to its rapid action in opening airways. Cromolyn (Choice B) is used for prevention rather than acute treatment. Methylprednisolone (Choice C) and Aminophylline (Choice D) are not the first-line treatments for acute wheezing in allergic reactions.

5. What should the nurse do if a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the solution container
• B. Increase the flow of the enema solution
• C. Stop the procedure and remove the tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.

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