Nursing Elites

1. When palpating the client's neck for lymphadenopathy, where should the nurse position herself?

• A. At the client's back
• B. At the client's right side
• C. At the client's left side
• D. In front of a sitting client

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position herself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Placing oneself in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect as positioning at the back or sides of the client may hinder proper assessment due to limited visibility and access to the neck area.

2. What is established when threats to air resources prevent evacuation by air from forward units?

• A. Area support medical battalions
• B. TOE units
• C. Ambulance exchange points
• D. Field hospitals

Correct answer: C

Rationale: Ambulance exchange points are set up when threats to air resources make it impossible to evacuate by air from forward units. These points serve as locations where patients can be transferred from ambulances to aircraft for further evacuation. Area support medical battalions (Choice A) are not directly related to this scenario, as they provide medical support to larger areas. TOE units (Choice B) refer to tables of organization and equipment, not specific to this situation. Field hospitals (Choice D) are more permanent facilities for treating patients and are not specifically for transferring patients under threats to air resources.

3. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

• A. All of the above
• B. “My abdominal muscles may be tender because of the procedure.”
• C. “My diet should be light at first, and then I can progress to a regular diet.”
• D. “It is normal to feel gassy or bloated for a short while after the procedure.”

Correct answer: A

Rationale: The correct answer is A: "All of the above." Evaluation of learning after a colonoscopy would be evident if the client mentions all the statements provided. Mild tenderness in the abdominal muscles, starting with a light diet and progressing to a regular diet, and experiencing gas or bloating temporarily are all expected after a colonoscopy. Therefore, all the statements are correct in demonstrating the client's understanding of the post-procedure instructions. Choices B, C, and D provide accurate information about the expected outcomes following a colonoscopy, making them incorrect answers individually but correct when combined as option A.

4. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

• A. Explain to the client that it is too early to have an injection for pain
• B. Call the practitioner, report the client’s symptoms, and obtain further orders
• C. Reposition the client for greater comfort and turn on the television as a distraction
• D. Prepare the injection and administer it to the client early because of the severe pain

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client’s symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.

5. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

• A. The client’s BP is 110/70
• B. The client’s potassium level is 3.4 mEq/L
• C. The client has a barky cough
• D. The client’s apical pulse is 56

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering a beta blocker as the blood pressure is within normal range. Choice B is not directly related to the administration of a beta blocker. Choice C may indicate a potential adverse effect of another medication, but it does not specifically warrant questioning the administration of the beta blocker.

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