Nursing Elites

1. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:

• A. tip of the nose to the base of the neck
• B. the distance from the tip of the nose to the middle of the neck
• C. the distance from the tip of the nose to the tip of the ear lobe
• D. eight to ten inches

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

2. The nurse is correct in performing suctioning when she applies the suction intermittently during:

• A. Insertion of the suction catheter
• B. Withdrawing of the suction catheter
• C. both insertion and withdrawing of the suction catheter
• D. When the suction catheter tip reaches the bifurcation of the trachea

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.

3. The PACU nurse will maintain postoperative T and A client in what position?

• A. Supine with neck hyperextended and supported with pillow
• B. Prone with the head on pillow and turned to the side
• C. Semi-fowler’s with neck flexed
• D. Reverse trendelenburg with extended neck

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.

4. Which of the following has the greatest effect on an increase in body weight?

• A. Carbohydrate intake
• B. Protein intake
• C. Fat intake
• D. Total kilocalories

Correct answer: D

Rationale: Total kilocalories have the greatest effect on body weight as they represent the overall energy intake from all macronutrients combined. While the consumption of specific macronutrients like carbohydrates, proteins, and fats can affect weight management, the total calories consumed play the most significant role in determining body weight. Therefore, choices A, B, and C are incorrect as they focus on individual macronutrients rather than the overall energy balance provided by total kilocalories.

5. 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.

Similar Questions