Nursing Elites

1. During the acute phase of a burn, the priority nursing intervention in caring for this client is:

• A. Prevention of infection
• B. Pain management
• C. Prevention of bleeding
• D. Fluid resuscitation

Correct answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.

2. 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.

3. After ileostomy, which of the following condition is NOT expected?

• A. Increased weight
• B. Irritation of skin around the stoma
• C. Liquid stool
• D. Establishment of regular bowel movement

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. The nurse’s most unique tool in working with the emotionally ill client is his/her

• A. theoretical knowledge
• B. personality make up
• C. emotional reactions
• D. communication skills

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. Induction of vomiting is indicated for the accidental poisoning patient who has ingested.

• A. Rust remover C. toilet bowl cleaner
• B. Gasoline D. aspirin
• C.
• D.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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