Nursing Elites

1. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

• A. Measuring and recording fluid intake and output
• B. Weighing the client daily at the same time each day
• C. Assessing the client’s vital signs every 4 hours
• D. Checking the client’s lungs for crackles during every shift

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

2. Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).

3. When a field medical element is not operational, it engages in training to achieve readiness for mobilization that involves all aspects of operation. Individuals must be proficient in their MOS/ASI and which of the following?

• A. Command and control procedures
• B. Computers and data processing
• C. Common soldier tasks
• D. Communications and automation

Correct answer: C

Rationale: In the context of field medical training for mobilization, proficiency in common soldier tasks is essential. This includes skills like first aid, navigation, marksmanship, and other fundamental military tasks. While command and control procedures, communications, and automation are important, common soldier tasks are specifically mentioned in the scenario as critical for achieving readiness and mobilization.

4. Which nursing action(s) can result in disciplinary action by state boards of nursing?

• A. Release of client health information to a client’s neighbor
• B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
• C. Release of client health information to the client’s durable power of attorney
• D. A, B

Correct answer: D

Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals, such as a client's neighbor (choice A) or improper delegation of nursing tasks to unlicensed personnel like UAPs (choice B), are violations of patient confidentiality and safety. Releasing client health information to the client's durable power of attorney (choice C) is a legal and appropriate action, not warranting disciplinary action. Therefore, choices A and B can result in disciplinary action by state boards of nursing, making option D the correct answer.

5. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement by the client indicates appropriate management?

• A. “I will brush my teeth with a soft-bristle toothbrush.”
• B. “I will rinse my mouth with Listerine mouthwash.”
• C. “I will swish my antifungal solution and then swallow.”
• D. “I will avoid spicy foods, tobacco, and alcohol.”

Correct answer: D

Rationale: The correct answer is D. Avoiding irritants like spicy foods, tobacco, and alcohol is crucial in managing mouth ulcers as they can further irritate the ulcers and delay healing. Choices A, B, and C could potentially worsen the condition. Brushing with a soft-bristle toothbrush may cause discomfort, rinsing with Listerine mouthwash can be too harsh on the ulcers, and swallowing antifungal solution is not recommended unless specified by a healthcare provider.

Similar Questions