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. High blood pressure is defined as systolic and diastolic measurements greater than or equal to:

• A. 140 mm Hg and 90 mm Hg, respectively
• B. 150 mm Hg and 80 mm Hg, respectively
• C. 160 mm Hg and 110 mm Hg, respectively
• D. 180 mm Hg and 120 mm Hg, respectively

Correct answer: A

Rationale: High blood pressure, or hypertension, is typically defined as having a systolic pressure of 140 mm Hg or higher and/or a diastolic pressure of 90 mm Hg or higher. Therefore, the correct answer is A. Choice B is incorrect because it suggests a higher systolic measurement than the standard definition. Choice C is incorrect as it provides an even higher systolic measurement and a much higher diastolic measurement. Choice D is also incorrect as it suggests extremely elevated blood pressure values, well above the typical definition of hypertension.

3. A client with Crohn's disease is being cared for by a nurse. Which of the following food choices aligns with the recommended diet for clients with Crohn's disease?

• A. Vanilla milkshake
• B. Buttered popcorn
• C. Tossed green salad
• D. Toast with jelly

Correct answer: C

Rationale: The correct answer is a 'Tossed green salad.' Clients with Crohn's disease often benefit from a low-residue diet, which includes easily digestible foods like leafy green vegetables found in a tossed green salad. This type of diet helps minimize gastrointestinal symptoms. Choices A, B, and D are not ideal for clients with Crohn's disease. Vanilla milkshake, buttered popcorn, and toast with jelly may exacerbate symptoms due to their high fat, fiber, or sugar content, which can be harder to digest.

4. What symptom would most likely be associated with late dumping syndrome?

• A. abdominal cramps
• B. nausea
• C. diarrhea
• D. confusion

Correct answer: D

Rationale: Confusion is the most likely symptom associated with late dumping syndrome. Late dumping syndrome occurs when blood sugar levels drop rapidly after eating due to rapid gastric emptying. While abdominal cramps, nausea, and diarrhea can occur with dumping syndrome, confusion is specifically linked to late dumping syndrome due to hypoglycemia.

5. Medication for treating high blood cholesterol levels should not be used for most people unless:

• A. The patient has at least three major risk factors for coronary heart disease
• B. The patient has been experiencing symptoms of coronary heart disease for at least three months
• C. The patient's medical insurance covers prescription drugs
• D. Treatment with Therapeutic Lifestyle Changes (TLC) alone is unsuccessful after three months

Correct answer: D

Rationale: The correct answer is choice D because medication for high cholesterol is typically not considered unless Therapeutic Lifestyle Changes (TLC), which include diet and exercise, have not proven effective after a three-month period. This approach ensures that lifestyle modifications are given a fair chance to lower cholesterol levels before resorting to medication. Choice A is incorrect because the number of risk factors for coronary heart disease does not dictate when to begin medication; it is about the effectiveness of lifestyle changes. Choice B is incorrect as the duration of coronary heart disease symptoms does not determine when to start medication; the focus is on the response to TLC. Choice C is incorrect because the coverage of prescription drugs by the patient's insurance does not influence the medical decision to use medication for high cholesterol; it is based on medical necessity and effectiveness of prior interventions.

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