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. Each statement is true of vitamin K, except one. Which is the exception?

• A. Vitamin K is produced in the gut.
• B. Vitamin K functions as a catalyst for the synthesis of blood-clotting factors.
• C. Vitamin K maintains prothrombin levels.
• D. Vitamin K absorption increases with high levels of vitamin E supplementation.

Correct answer: D

Rationale: The correct answer is D. Vitamin K absorption decreases with high levels of vitamin E supplementation because in larger amounts, vitamin E acts as an anticoagulant. Vitamin K is not produced in the gut but can be obtained from food sources or supplements. Vitamin K is essential for the synthesis of blood-clotting factors and is crucial in maintaining prothrombin levels, which is vital for proper blood clotting. The incorrect choice, D, is misleading as high levels of vitamin E supplementation hinder vitamin K absorption due to its anticoagulant properties. Dental hygienists should be aware of the importance of vitamin K in blood clotting, especially when treating patients who are on anticoagulant medications for conditions like stroke prevention.

3. A client who is 2 days postoperative following abdominal surgery is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

• A. Cranberry juice
• B. Flavored gelatin
• C. Skim milk
• D. Chicken broth

Correct answer: A

Rationale: Cranberry juice is an appropriate choice for a client transitioning from a clear liquid diet to full liquids post abdominal surgery. It provides hydration and some essential nutrients. Flavored gelatin is usually allowed on a clear liquid diet and may not be suitable for a full liquids phase. Skim milk and chicken broth are typically introduced in a later stage of the diet progression, closer to a soft diet, due to their higher protein and fat content.

4. Which organ produces and secretes bicarbonate ions and insulin?

• A. Stomach
• B. Pancreas
• C. Large intestine
• D. Small intestine

Correct answer: B

Rationale: The pancreas is the correct answer because it performs two vital functions: producing bicarbonate ions to neutralize stomach acid in the small intestine and secreting insulin to regulate blood glucose levels. The stomach is incorrect because its primary function is to break down and digest food, not produce bicarbonate ions or insulin. The large and small intestines are also incorrect because their primary functions are to absorb nutrients and water from food, rather than producing bicarbonate ions or insulin.

5. A client has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?

• A. Replace the bag and tubing every 24 hours
• B. Flush the tubing with 10 mL water every 6 hours
• C. Administer the feeding by gravity drip
• D. Heat the formula prior to infusion

Correct answer: B

Rationale: To prevent clogging when using high-viscosity formulas in a small-bore jejunostomy, the nurse should flush the tubing with 10 mL of water every 6 hours. This action helps maintain tube patency and prevent blockages. Replacing the bag and tubing every 24 hours (Choice A) is unnecessary and does not specifically address preventing clogging. Administering the feeding by gravity drip (Choice C) or heating the formula prior to infusion (Choice D) are not effective interventions for preventing tubing clogging.

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