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. Intrinsic factor from the stomach is needed for the absorption of which vitamin?

• A. vitamin B12
• B. folate
• C. niacin
• D. vitamin B6

Correct answer: A

Rationale: The correct answer is A: vitamin B12. Intrinsic factor is a glycoprotein produced by the stomach that is necessary for the absorption of vitamin B12 in the small intestine. Vitamin B12 binds to intrinsic factor in the stomach, forming a complex that is then absorbed in the ileum. This absorption process is crucial for preventing vitamin B12 deficiency. Choices B, C, and D are incorrect because they do not require intrinsic factor for absorption. Folate is absorbed in the small intestine through a different mechanism, niacin can be absorbed in the small intestine without the need for intrinsic factor, and vitamin B6 does not rely on intrinsic factor for absorption.

3. A patient tells the nurse “I am depressed to talk to you, leave me alone” Which of the following response by the nurse is most therapeutic?

• A. I’ll be back in an hour
• B. Why are you so depressed?
• C. I’ll seat with you for a moment
• D. Call me when you feel like talking to me

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.

4. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT:

• A. Avoid emotional stress and extreme temperature
• B. Avoid pollution like smoking
• C. Avoid pollens, dust, seafood
• D. Practice respiratory isolation

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.

5. The principal cation in plasma and interstitial fluid is:

• A. Sodium
• B. Potassium
• C. Calcium
• D. Magnesium

Correct answer: A

Rationale: The principal cation in plasma and interstitial fluid is sodium. Sodium plays a crucial role in maintaining fluid balance and is the primary cation in extracellular fluids like plasma and interstitial fluid. Potassium is the primary cation within cells, not in extracellular fluids, making it an incorrect choice. Calcium and magnesium are essential minerals but are not the principal cations in plasma and interstitial fluid, so they are also incorrect choices.

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