Nursing Elites

1. This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in patient care and factors related to daily living activities. This record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. What record is this?

• A. Discharge Summary
• B. Medicine and Treatment Record
• C. Nursing Health History and Assessment Worksheet
• D. Nursing Kardex

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.

2. A client is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?

• A. Lemon-lime soda
• B. Brewed iced tea
• C. Diet cola
• D. Chocolate milk

Correct answer: B

Rationale: The nurse should recommend brewed iced tea as it generally contains less caffeine compared to other choices. Lemon-lime soda, diet cola, and chocolate milk all contain caffeine, which can contribute to sleep disturbances. Lemon-lime soda and diet cola are carbonated beverages that typically contain caffeine unless specified as caffeine-free. Chocolate milk also contains caffeine due to the cocoa content. Therefore, brewed iced tea is the most suitable choice to reduce caffeine intake and improve sleep quality.

3. 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.

4. Which type of assessment evaluates a person's risk of malnutrition by ranking key variables from the medical history and physical examination?

• A. Katz index
• B. integrated assessment
• C. subjective global assessment
• D. nutrition care plan

Correct answer: C

Rationale: The Subjective Global Assessment (SGA) is the correct choice. SGA is a comprehensive tool used to assess an individual's risk of malnutrition by integrating key variables from the medical history, physical examination, and other relevant factors. The Katz index is used to assess activities of daily living, not malnutrition risk. An integrated assessment refers to the overall evaluation process involving multiple assessments. A nutrition care plan is a personalized plan developed based on assessment findings, not the assessment itself.

5. Which of the following is a common sign of vitamin D deficiency?

• A. Brittle nails
• B. Muscle weakness
• C. Night blindness
• D. Hair loss

Correct answer: B

Rationale: Muscle weakness is a common sign of vitamin D deficiency. Vitamin D is essential for calcium absorption and bone health, and its deficiency can lead to muscle weakness. Brittle nails (Choice A) are not typically associated with vitamin D deficiency. Night blindness (Choice C) is related to vitamin A deficiency, not vitamin D deficiency. Hair loss (Choice D) can be linked to various factors, but it is not a common sign of vitamin D deficiency.

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