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 for a client with fluid volume deficit include monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. Monitoring vital signs helps in early detection of changes, daily weighing can indicate fluid retention or loss, and skin turgor assessment is a reliable indicator of hydration status. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and should not be included in the plan of care for this specific condition.

2. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

• A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
• B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
• C. 56-year-old fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization
• D. 86-year-old; 48 hours postoperative repair of fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter

Correct answer: A

Rationale: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.

3. Which of the following is a primary factor that affects blood pressure?

• A. Obesity
• B. Age
• C. Stress
• D. Gender

Correct answer: A

Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure but are not primary factors like obesity.

4. During the admission interview, which question should the nurse ask the male client diagnosed with aorto-iliac disease?

• A. “Do you have trouble sitting for long periods of time?”
• B. “How often do you have a bowel movement and urinate?”
• C. “When you lie down do you feel throbbing in your abdomen?”
• D. “Have you experienced any problems having sexual intercourse?”

Correct answer: D

Rationale: The correct question for the nurse to ask the male client diagnosed with aorto-iliac disease during the admission interview is about any problems experienced during sexual intercourse. Aorto-iliac disease can lead to impaired blood flow to the pelvis and lower extremities, affecting sexual function. Therefore, it is essential to assess the client's sexual health in such cases. The other options, such as sitting for long periods of time, bowel movements and urination frequency, and throbbing sensation when lying down, are not directly related to the potential impact of aorto-iliac disease on sexual function. Hence, they are not the most pertinent questions to ask during the admission interview.

5. What is the COMMZ level hospital whose principal mission is to treat and rehabilitate those patients who can return to duty within the stated theater evacuation policy?

• A. FSB
• B. CSH
• C. GH
• D. FH

Correct answer: C

Rationale: The correct answer is C, GH (General Hospital), as it is the COMMZ level hospital that focuses on treating and rehabilitating patients who can return to duty within the theater evacuation policy. FSB (Forward Surgical Hospital) primarily provides surgical care close to the front lines. CSH (Combat Support Hospital) offers more comprehensive surgical and medical care than FSB but does not focus on rehabilitation like GH. FH (Field Hospital) provides initial medical care and stabilization before patients are evacuated to higher-level facilities.

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