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. A nurse is planning care for a toddler who has burns over 50% total body surface area. Which of the following actions should the nurse include in the plan of care?

• A. Administer enteral feedings
• B. Limit intake of vitamin C
• C. Limit dietary protein
• D. Administer insulin prior to meals

Correct answer: A

Rationale: Administering enteral feedings is crucial for ensuring adequate nutrition and supporting healing in toddlers with extensive burns. Burns over 50% total body surface area can lead to increased metabolic demands, making it essential to provide nutrition through enteral feedings to meet the child's needs for healing and recovery. Limiting intake of vitamin C or dietary protein would be detrimental in this scenario as the child requires increased amounts of nutrients to support healing. Administering insulin prior to meals is not indicated in this case as the priority is to provide adequate nutrition to promote healing.

3. Which nutrient is most closely associated with the prevention of neural tube defects in a developing fetus for a woman planning to become pregnant?

• A. Calcium
• B. Folate
• C. Vitamin A
• D. Choline

Correct answer: B

Rationale: The correct answer is folate. Folate, also known as Vitamin B9, is vital for the prevention of neural tube defects in the developing fetus. It is primarily responsible for the creation and repair of DNA, which is essential during rapid growth stages such as pregnancy. While nutrients like calcium, vitamin A, and choline are important for pregnancy, they are not as directly linked to preventing neural tube defects as folate. Calcium is crucial for the baby's bone and teeth development. Vitamin A is essential for vision, immune function, and cellular growth. Choline supports brain development and neural functioning. However, none of these nutrients have the same direct impact on preventing neural tube defects as folate.

4. A client who has dumping syndrome following a hemi-colectomy should avoid which of the following foods when receiving nutritional teaching from a nurse?

• A. Rice
• B. Poached eggs
• C. Fresh apples
• D. White bread

Correct answer: C

Rationale: Fresh apples should be avoided by a client with dumping syndrome following a hemi-colectomy because they are high in fiber and can exacerbate gastrointestinal symptoms such as diarrhea and bloating. Rice and poached eggs are good options as they are easily digestible and less likely to trigger dumping syndrome symptoms. White bread is also preferable over whole grain bread due to its lower fiber content, making it a better choice for individuals with dumping syndrome.

5. This quality is being demonstrated by a Nurse who raise the side rails of a confused and disoriented patient?

• A. Autonomy
• B. Responsibility
• C. Prudence
• D. Resourcefulness

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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