Nursing Elites

1. The nurse is caring for a client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt drain
• B. Guarding when the nurse touches the abdomen
• C. Tenderness around the surgical site during palpation
• D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.

2. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

• A. Instruct the client to avoid drinking fluids with meals
• B. Explain the need to decrease intake of flatus-forming foods
• C. Teach the client how to perform gentle perianal care
• D. Encourage the client to see a psychologist

Correct answer: B

Rationale: Choosing option B, explaining the need to decrease intake of flatus-forming foods, is the correct intervention to reduce IBS symptoms. Flatus-forming foods can worsen bloating and discomfort in individuals with IBS. Option A, instructing the client to avoid drinking fluids with meals, may be helpful for other conditions but is not a primary intervention for IBS. Option C, teaching perianal care, is not directly related to reducing IBS symptoms. Option D, encouraging the client to see a psychologist, may be beneficial for managing stress related to IBS but is not the initial intervention to reduce symptoms.

3. Which of the following is a nonmedical member of a unit who receives additional training in providing care beyond basic first aid procedures?

• A. Area support squad leader
• B. ATLS specialist
• C. Tactical lifesaver
• D. Combat lifesaver

Correct answer: D

Rationale: The correct answer is D, 'Combat lifesaver.' A Combat Lifesaver is a nonmedical member of a unit who is trained in advanced first aid procedures, providing care beyond basic first aid. Choice A, 'Area support squad leader,' does not specifically refer to someone trained in providing advanced care. Choice B, 'ATLS specialist,' refers to someone trained in Advanced Trauma Life Support (ATLS), which is beyond the scope of the question. Choice C, 'Tactical lifesaver,' is not a recognized term for the role described in the question.

4. What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?

• A. Assess the intravenous fluids for rate and volume
• B. Change the surgical dressing every day at the same time
• C. Monitor the client’s medication levels daily
• D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.

5. Which of the following statements does NOT apply to a nursing plan of care?

• A. It contains short-term goals
• B. It is developed by the patient's physician
• C. It must be continually evaluated
• D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

Similar Questions