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. What instruction should the nurse include on weight gain during pregnancy?

• A. Failure to obtain the required weight gain during pregnancy will increase the risk of preterm birth.
• B. An obese client needs to gain as much weight as a client with a normal body mass index.
• C. A client with a normal body mass index should plan on gaining 50 pounds.
• D. Clients will need to eat for two when they are pregnant.

Correct answer: A

Rationale: Appropriate weight gain is crucial for reducing the risk of preterm birth.

3. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

• A. Oliguria and jaundice
• B. Urticaria and wheezing
• C. Headache, chills, & fever
• D. Hypertension and flushing

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. Which topical antimicrobial is most frequently used in burn wound care?

• A. Neosporin
• B. Silver nitrate
• C. Silver sulfadiazine
• D. Sulfamylon

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.

5. In consideration of the steps in applying the bag technique, which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area?

• A. The lower lip
• B. The outer surface
• C. The upper tip
• D. The inside surface

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.

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