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. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

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.

3. Which assessment finding indicates effective treatment for hyperemesis gravidarum?

• A. The client's glucose is within the normal range.
• B. The client ate 80% of their breakfast tray.
• C. There is no protein in the client's urine.
• D. The client's blood pressure is 145/75 mmHg.

Correct answer: B

Rationale: Improved appetite and food intake is an indication of effective treatment.

4. Select all that apply. Characteristics of the 2 main types of essential fatty acids discussed in class include:

• A. they must be supplied by the diet
• B. they can be produced by a process called dehydrogenation
• C. they are anti-inflammatory
• D. they are all polyunsaturated fatty acids

Correct answer: A

Rationale: The correct answer is A: 'they must be supplied by the diet.' Essential fatty acids, like omega-3 and omega-6, cannot be produced by the body and must be obtained through the diet. They are polyunsaturated fatty acids, playing vital roles in inflammation and cell membrane structure. Choice B is incorrect because essential fatty acids cannot be produced by dehydrogenation, a process of removing hydrogen. Choice C is incorrect as not all essential fatty acids are anti-inflammatory; some have pro-inflammatory roles. Choice D is incorrect because not all essential fatty acids are polyunsaturated; omega-9, for example, is a monounsaturated essential fatty acid.

5. Which of the following are examples of mechanical digestion? Select all that apply.

• A. Heat
• B. Segmentation
• C. Option B and D
• D. Peristalsis

Correct answer: C

Rationale: Mechanical digestion involves physical movements that break down food in the digestive tract. Segmentation (choice B) and peristalsis (choice D), which are both movements of the muscles in the digestive tract, are examples of this type of digestion. Heat (choice A), on the other hand, is related to chemical digestion, not mechanical digestion. Therefore, choice C (Option B and D) is the correct answer as it includes both examples of mechanical digestion provided in the choices. Choices A and D are incorrect because heat (choice A) is not a mechanical digestion process, and peristalsis (choice D) is a movement that helps propel food along the digestive tract but is not directly involved in breaking down food physically.

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