Nursing Elites

1. The system used at the division level and forward comprises six basic modules. Which module is composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients?

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

Correct answer: B

Rationale: The Patient Holding Squad is the module composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients. The other choices are incorrect because a 'Treatment squad' would typically involve a broader range of medical care, an 'Area support squad' is more general and focuses on providing overall support in a specific area, and a 'Surgical squad' would be specifically focused on surgical procedures rather than general medical care for minimal care patients.

2. 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.

3. In patients with heart failure, which type of diet is most recommended?

• A. High-sodium
• B. Low-sodium
• C. High-fat
• D. Low-carbohydrate

Correct answer: B

Rationale: In patients with heart failure, a low-sodium diet is most recommended. This type of diet helps manage fluid retention by reducing the amount of sodium in the body. Excess sodium can lead to fluid accumulation, putting additional strain on the heart. High-sodium diets can exacerbate symptoms of heart failure by causing fluid retention and increasing blood pressure. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients and may not address the underlying issues related to fluid balance and heart function.

4. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

• A. Encouraging family discussion of feelings
• B. Accepting the family’s experience of anger
• C. Facilitating the use of spiritual practices identified by the family
• D. All of the above

Correct answer: D

Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.

5. During a physical assessment of a newborn, what finding should the nurse prioritize reporting?

• A. Head circumference of 40 cm
• B. Chest circumference of 32 cm
• C. Acrocyanosis and edema of the scalp
• D. Heart rate of 160 bpm and respirations of 40/min

Correct answer: A

Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.

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