Nursing Elites

1. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair.
• B. The assistant inserted two (2) fingers under the proximal end of the stocking.
• C. The assistant elevated the feet while lying down to put on the stockings.
• D. The assistant made sure the toes were warm after putting the stockings on.

Correct answer: A

Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.

2. During synchronized cardioversion on a client in atrial fibrillation, when the machine is activated, and there is a pause, what action should the nurse take?

• A. Wait until the machine discharges
• B. Shout “all clear” and don’t touch the bed
• C. Make sure the client is all right
• D. Increase the joules and re-discharge

Correct answer: B

Rationale: The correct action for the nurse to take when there is a pause after the machine is activated during synchronized cardioversion is to shout “all clear” and ensure that no one is touching the client or the bed to prevent them from being shocked. This step is crucial for the safety of everyone present during the procedure. Choices A, C, and D are incorrect because waiting without confirming safety, focusing on the client's condition only, or increasing joules without safety precautions can lead to potential harm or injury.

3. Who is the first individual in the combat health support chain to make medically substantiated decisions based on military occupational specialty-specific medical training?

• A. Physician
• B. Physician Assistant
• C. Combat medic
• D. Combat lifesaver

Correct answer: B

Rationale: The Physician Assistant is the first individual in the combat health support chain to make medically substantiated decisions based on their military occupational specialty-specific medical training. While physicians are highly trained medical professionals, in the context of combat health support, the Physician Assistant is typically the frontline provider who directly applies their specific military medical training to make decisions. Combat medics and combat lifesavers may provide critical care in the field, but they do not have the same level of training and scope of practice as a Physician Assistant in this context, making them less likely to be the first to make medically substantiated decisions.

4. The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client?

• A. Keep the area between the toes dry.
• B. Wear comfortable, well-fitting shoes.
• C. Cut toenails straight across.
• D. A,B

Correct answer: D

Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry to prevent moisture-related skin issues and wearing comfortable, well-fitting shoes to prevent injury and promote circulation. Cutting toenails straight across is important to prevent ingrown toenails, but in this case, an arch cut can lead to injury. Therefore, choices A and B are correct, making option D the most appropriate answer. Choice C is incorrect in this context.

5. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to:

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

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