Nursing Elites

1. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt
• 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. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

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. Where do most peptic ulcers occur?

• A. Esophagus
• B. Stomach
• C. Duodenum
• D. Jejunum

Correct answer: C

Rationale: Most peptic ulcers occur in the duodenum, particularly in cases of duodenal ulcers. The correct answer is the duodenum because it is the most common site for peptic ulcers to develop. Peptic ulcers rarely occur in the esophagus and jejunum, making choices A, B, and D incorrect.

4. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

• A. Instruct the client to delay intercourse until menses
• B. Schedule the client for frequent pelvic sonograms
• C. Explain that the infusion therapy will take 21 days
• D. Discuss that this may cause an ectopic pregnancy

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (Choice A) is not directly related to monitoring for ovarian hyperstimulation. Explaining the duration of infusion therapy (Choice C) is not relevant to monitoring for this specific complication. Discussing the risk of ectopic pregnancy (Choice D) is important, but it is not the most appropriate intervention for monitoring ovarian hyperstimulation.

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

• 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: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.

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