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. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

3. Nutritional goals for a patient wishing to modify eating patterns should adhere to each, except one. Which is the exception?

• A. Measurable
• B. Immediate
• C. Realistic
• D. Achievable

Correct answer: B

Rationale: Nutritional goals should be measurable, realistic, and achievable. They should not be immediate, as sustainable changes take time.

4. Which type of nutritional deficiency results from inadequate absorption?

• A. Unmeasurable
• B. Primary deficiency
• C. Secondary deficiency
• D. Codependent

Correct answer: C

Rationale: The correct answer is C: Secondary deficiency. A nutritional deficiency resulting from decreased intake is called a primary deficiency. On the other hand, a secondary deficiency refers to a vitamin deficiency caused by inadequate absorption or use, increased requirements, excretion, or destruction. Choice A, 'Unmeasurable,' is incorrect as it does not describe a type of nutritional deficiency. Choice B, 'Primary deficiency,' is incorrect as it refers to a deficiency caused by decreased intake, not inadequate absorption. Choice D, 'Codependent,' is incorrect as it is unrelated to the context of nutritional deficiencies.

5. In a patient with liver cirrhosis, weight gain due to fluid retention can mask the symptoms of what condition?

• A. Liver failure
• B. Gallbladder disease
• C. Heart failure
• D. Protein-Energy Malnutrition (PEM)

Correct answer: D

Rationale: In a patient with liver cirrhosis, weight gain due to fluid retention can mask Protein-Energy Malnutrition (PEM) symptoms. This can lead to an increase in weight, making it challenging to identify weight loss or muscle wasting associated with PEM. Therefore, option D is correct. Options A, B, and C are incorrect because fluid retention and weight gain related to liver cirrhosis do not necessarily hide the symptoms of liver failure, gallbladder disease, or heart failure.

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