Nursing Elites

1. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

• A. Monitor vital signs every two (2) hours until stable
• B. Weigh the client in the same clothing at the same time daily
• C. Administer mouth care every eight (8) hours
• D. A, B, and C

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

2. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

• A. Establish a rapport with the client to decrease embarrassment when assessing the site
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to allow the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.

3. A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?

• A. I will take this medication on an empty stomach.
• B. I will take the morning dose 1 hour before breakfast.
• C. I will need to avoid taking this medication with coffee.
• D. I will take antacids if needed, 2 hours after I take ferrous sulfate.

Correct answer: A

Rationale: The correct answer is A. Ferrous sulfate should be taken on an empty stomach to improve absorption. Choice A is incorrect as taking the medication with a full glass of milk would impair iron absorption. Choices B, C, and D are all correct statements regarding the administration of ferrous sulfate. Choice B ensures proper timing before breakfast, choice C highlights avoiding coffee due to interference with iron absorption, and choice D correctly suggests taking antacids a few hours after ferrous sulfate to prevent potential interactions.

4. The system used at the division level and forward is comprised of six basic modules. Which module is composed of a dental officer, dental specialist, x-ray specialist, laboratory specialist, and needed equipment?

• A. Treatment squad
• B. Area support squad
• C. Medical service squad
• D. Dental squad

Correct answer: D

Rationale: The correct answer is D, Dental squad. The Dental squad is composed of a dental officer, dental specialist, x-ray specialist, laboratory specialist, and necessary equipment. This module specifically focuses on dental care and services. Choices A, B, and C are incorrect as they do not include the specific specialists mentioned in the question or focus on dental services.

5. Short-bowel syndrome usually occurs when:

• A. The longitudinal muscles of the intestine contract
• B. More than 50% of the small intestine is surgically removed
• C. More than 50% of the large intestine is surgically removed
• D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

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