Nursing Elites

1. During the first 24 hours after the thermal injury, you should assess Sergio for:

• A. hypokalemia and hypernatremia
• B. hypokalemia and hyponatremia
• C. hyperkalemia and hyponatremia
• D. hyperkalemia and hypernatremia

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

2. During nutritional counseling, what is the most important step to take?

• A. Consult the patient's family
• B. Formulate a sample diet plan before presenting it to the patient
• C. Include members of the dental team in the dietary formulation
• D. Include the patient in the formulation of the dietary plan

Correct answer: D

Rationale: During nutritional counseling, the most important step is to include the patient in the formulation of the dietary plan. This ensures their active involvement, understanding, and commitment to the plan, leading to better compliance and success in achieving nutritional goals. Consulting the patient's family (Choice A) may be helpful but should not replace involving the patient directly. Formulating a sample diet plan before presenting it to the patient (Choice B) may not align with the patient's preferences or needs. Including members of the dental team in the dietary formulation (Choice C) may not be necessary unless specific dental concerns need to be addressed.

3. Which enzyme is most essential for hydrolyzing large protein molecules?

• A. Gastric lipase
• B. Pepsin
• C. Mucus
• D. Intrinsic factor

Correct answer: B

Rationale: Pepsin, choice B, is the correct answer as it is a proteolytic enzyme that is essential for the breakdown of large protein molecules in the stomach. Gastric lipase, choice A, is incorrect because it primarily targets fats, not proteins, hence it is not involved in protein hydrolysis. Mucus, choice C, is incorrect as it serves to protect the stomach lining from acidic gastric juices and does not play a direct role in protein digestion. Intrinsic factor, choice D, is incorrect as it is vital for the absorption of Vitamin B12 in the small intestine and doesn't participate in the process of hydrolyzing proteins.

4. Before administration of blood and blood products, the nurse should first:

• A. Check with another R.N the client’s name, Identification number, ABO and RH type.
• B. Explain the procedure to the client
• C. Assess baseline vital signs of the client
• D. Check for the BT order

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. What activities best describe the work of the placenta during pregnancy?

• A. surrounding and cushioning the fetus
• B. combining maternal and fetal blood stores to exchange nutrients
• C. producing hormones that maintain the pregnancy
• D. absorbing vitamins and minerals that can be transferred to the fetus

Correct answer: C

Rationale: The placenta plays a crucial role in producing hormones that are necessary for maintaining pregnancy, supporting fetal development, and preparing the mother's body for childbirth. Choices A, B, and D are incorrect because the placenta's primary function is not to surround and cushion the fetus, combine blood stores for nutrient exchange, or absorb vitamins and minerals. While the placenta does facilitate the exchange of nutrients and oxygen between the mother and fetus, its hormone production is the most critical function during pregnancy.

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