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. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?

• A. “Has your child had any sore throats?”
• B. “Has your child been eating properly?”
• C. “Is your child allergic to any antibiotics?”
• D. “Has your child been exposed to any infections?”

Correct answer: C

Rationale: The correct question the nurse should ask the mother before administering an MMR vaccine to a 15-month-old is whether the child is allergic to any antibiotics. This is crucial because vaccines like MMR contain components that the child could be allergic to, such as neomycin. Checking for antibiotic allergies is essential to prevent adverse reactions to the vaccine. The other options are less relevant in this context. Asking about sore throats, eating habits, or exposure to infections does not directly impact the administration of the MMR vaccine.

3. Which of the following is a specialized medical treatment and teaching facility that provides general and specialized medical and dental care and treatment?

• A. CONUS
• B. MEDCEN
• C. MEDCOM
• D. MEDDAC

Correct answer: B

Rationale: The correct answer is B, 'MEDCEN.' A MEDCEN (Medical Center) is a specialized medical treatment and teaching facility that offers general and specialized medical and dental care. Choice A, 'CONUS,' refers to the continental United States and is not related to medical facilities. Choice C, 'MEDCOM,' stands for Medical Command, which is an administrative entity responsible for overseeing medical units, not providing direct care. Choice D, 'MEDDAC,' refers to Medical Department Activity, which is a smaller medical unit compared to a MEDCEN and may not provide the same level of specialized care.

4. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

5. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

• A. Encouraging family discussion of feelings
• B. Accepting the family’s experience of anger
• C. Facilitating the use of spiritual practices identified by the family
• D. All of the above

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

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