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. What should a healthcare professional monitor for in a patient with compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized redness and swelling
• C. Fever and signs of infection
• D. Loss of deep tendon reflexes

Correct answer: A

Rationale: Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome. In this condition, increased pressure within a muscle compartment impairs blood flow, leading to severe pain that is not relieved by usual measures, pallor from decreased blood flow, and pulselessness due to compromised circulation. These signs indicate a medical emergency requiring immediate intervention. Localized redness and swelling (Choice B) are more characteristic of inflammation or infection rather than compartment syndrome. Fever and signs of infection (Choice C) are not typical manifestations of compartment syndrome. Loss of deep tendon reflexes (Choice D) is associated with conditions affecting the nervous system, not compartment syndrome.

3. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

• A. 1 packet of reconstituted dry onion soup
• B. 3 oz of lean cured ham
• C. 3 oz of chicken breast
• D. ½ cup of canned baked beans

Correct answer: C

Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Chvostek's sign
• C. Hyperactive bowel sounds
• D. Dry mucous membranes

Correct answer: A

Rationale: Corrected deep tendon reflexes occur with hyponatremia. Other manifestations of hyponatremia include headache, confusion, lethargy, fatigue, seizures, and muscle weakness. Positive Chvostek's sign is associated with hypocalcemia, hyperactive bowel sounds are not typically related to hyponatremia, and dry mucous membranes are more commonly seen with dehydration.

5. What is the priority lab value for monitoring a patient with HIV?

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

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it serves as a key indicator of immune function. A count below 180 cells/mm3 indicates severe immunocompromise and an increased risk of opportunistic infections. Choice B, serum albumin levels, though important for assessing nutritional status, is not the priority lab value for HIV monitoring. Choice C, white blood cell count, is a nonspecific measure of immune function and may not accurately reflect the status of the immune system in HIV patients. Choice D, hemoglobin levels, are essential for evaluating anemia but are not the primary lab value for monitoring HIV.

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