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. For individuals with lactose intolerance, which of the following foods should be avoided?

• A. Eggs
• B. Milk
• C. Almonds
• D. Beef

Correct answer: B

Rationale: Individuals with lactose intolerance lack the enzyme lactase needed to break down lactose. Milk contains lactose, a sugar found in dairy products, and should be avoided by individuals with lactose intolerance. Choices A, C, and D are not sources of lactose and are generally well-tolerated by individuals with lactose intolerance.

3. As a nurse assigned for care for geriatric patients, you need to frequently assess your patient using the nursing process. Which of the following needs be considered with the highest priority?

• A. Patients own feeling about his illness
• B. Safety of the client especially those elderly clients who frequently falls
• C. Nutritional status of the elderly client
• D. Physiologic needs that are life threatening

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. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

• A. Lubricates the tip of the catheter prior to inserting into the stoma
• B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
• C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
• D. Clamps of the flow of fluid when felling uncomfortable

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. Which of the following is a normal change observed in an elderly individual?

• A. Enhanced sense of taste
• B. Increased appetite
• C. Frequent urination
• D. Lens thinning

Correct answer: C

Rationale: The correct answer is C, frequent urination. As people age, they may experience physiological changes that can lead to an increased frequency of urination. This is due to a decrease in bladder capacity and increased bladder irritability, which are normal age-related changes. On the contrary, the sense of taste (Choice A) and appetite (Choice B) often decrease with age, not increase. As for Choice D, the lens of the eye actually thickens with age, not thins, leading to conditions like presbyopia. Therefore, Choices A, B, and D are incorrect.

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