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. A client is being taught about foods to include in a low-fiber diet. Which statement indicates the client understands the teaching?

• A. "A fresh pear would be a good snack option."?
• B. "I can prepare refried beans for supper."?
• C. "Bran cereal would be a good breakfast choice."?
• D. "I should choose white rice as a side dish."?

Correct answer: D

Rationale: The correct answer is "I should choose white rice as a side dish." In a low-fiber diet, foods that are low in fiber are recommended to reduce gastrointestinal irritation. White rice is a low-fiber option suitable for this diet. Choices A, B, and C are high-fiber options and not suitable for a low-fiber diet. A fresh pear, refried beans, and bran cereal are all high in fiber, which should be avoided in a low-fiber diet.

3. What is the desirable resting systolic blood pressure for adults?

• A. <130 mmHg>
• B. <105 mmHg>
• C. <120 mmHg>
• D. <140 mmHg>

Correct answer: C

Rationale: The desirable resting systolic blood pressure for adults is less than 120 mmHg. This blood pressure is associated with a lower risk of cardiovascular disease. Measurements higher than 120 mmHg (choices A and D) indicate elevated blood pressure, which can lead to hypertension and other health complications if not managed. A reading of less than 105 mmHg (choice B) could indicate low blood pressure, which also poses health risks such as dizziness and fainting.

4. In responding to the care concerns of children with severe disease, referral to the hospital is of the essence especially if the child manifests which of the following?

• A. Wheezing
• B. Stop feeding well
• C. Fast breathing
• D. Difficulty to awaken

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.

5. Which food items should be avoided by a child with lactose intolerance?

• A. Popcorn, seeds, and any foods containing nuts.
• B. Milk, cheese, ice cream, and puddings.
• C. Wheat, rye, barley, and commercially baked goods.
• D. Eggs, ham, bacon, and canned meats.

Correct answer: B

Rationale: The correct answer is B: Milk, cheese, ice cream, and puddings should be avoided by a child with lactose intolerance because they contain lactose, which the child's body may have difficulty digesting. Option A is incorrect as popcorn, seeds, and foods containing nuts do not typically contain lactose. Option C lists wheat, rye, barley, and commercially baked goods, which are sources of gluten, not lactose. Option D includes eggs, ham, bacon, and canned meats, which are also not sources of lactose. Therefore, B is the most appropriate choice for a child with lactose intolerance.

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