Nursing Elites

1. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.

2. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

• A. Pulmonary embolism
• B. Decreased urine output
• C. Hemoptysis
• D. Deep vein thrombosis

Correct answer: B

Rationale: The correct answer is B: Decreased urine output. When vegetative lesions from the mitral valve embolize, they can block blood flow to the kidneys, leading to renal infarction. This can result in decreased urine output. Choices A, C, and D are incorrect. Pulmonary embolism involves a blockage of an artery in the lungs, not directly related to embolization from the mitral valve. Hemoptysis is the coughing up of blood from the respiratory tract, which is not a direct consequence of embolization from the mitral valve. Deep vein thrombosis is the formation of a blood clot in a deep vein, unrelated to embolization from the mitral valve.

3. A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

• A. Flushing
• B. Dyspnea
• C. Tachycardia
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. Flushing (choice A) is not a typical side effect of albuterol. Dyspnea (choice B) refers to difficulty breathing, which is a symptom of asthma but not a common side effect of albuterol. Hypotension (choice D) is low blood pressure, which is not a common side effect associated with albuterol use.

4. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

• A. “I should increase fruits, bran, and fluids in my diet.”
• B. “I will use warm compresses and take sitz baths daily.”
• C. “I must take a laxative every night and have a stool daily.”
• D. “I can use an analgesic ointment or suppository for pain.”

Correct answer: C

Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.

5. The system used at the division level and forward comprises six basic modules. Which module is composed of four medical specialists and two vehicles?

• A. Patient holding squad
• B. Surgical squad
• C. Ambulance squad
• D. Area support squad

Correct answer: C

Rationale: The correct answer is 'C: Ambulance squad.' The Ambulance Squad is composed of four medical specialists and two vehicles, making it the module described in the question. Choice A, 'Patient holding squad,' is incorrect as it does not match the composition specified. Choice B, 'Surgical squad,' is incorrect as it focuses on surgical rather than general medical support. Choice D, 'Area support squad,' is incorrect as it does not align with the composition of four specialists and two vehicles.

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