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. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

3. 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.

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 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.

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