Nursing Elites

1. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.

2. In patients with heart failure, which type of diet is most recommended?

• A. High-sodium
• B. Low-sodium
• C. High-fat
• D. Low-carbohydrate

Correct answer: B

Rationale: In patients with heart failure, a low-sodium diet is most recommended. This type of diet helps manage fluid retention by reducing the amount of sodium in the body. Excess sodium can lead to fluid accumulation, putting additional strain on the heart. High-sodium diets can exacerbate symptoms of heart failure by causing fluid retention and increasing blood pressure. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients and may not address the underlying issues related to fluid balance and heart function.

3. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

• A. Discontinue the heparin drip prior to initiating the Coumadin
• B. Check the client’s INR prior to beginning Coumadin
• C. Clarify the order with the health care provider as soon as possible
• D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.

4. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

• A. Deep tendon reflexes
• B. Arterial blood gases
• C. Skin turgor
• D. Capillary refill time

Correct answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

5. What is the combat health support system in the field designed to do?

• A. Provide evacuation to the far rear for treatment and delay return to duty
• B. Project, sustain, and protect the health of the soldier in war and operations other than war
• C. Provide rearward evacuation and reassignment
• D. Provide far rear area care and delayed return to duty

Correct answer: B

Rationale: The correct answer is B. The combat health support system in the field is designed to project, sustain, and protect the health of soldiers in both war and operations other than war. Choice A is incorrect because the system is not primarily focused on providing evacuation to the far rear for treatment, but rather on overall health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is a limited scope compared to the comprehensive support provided by the system. Choice D is incorrect as it narrowly focuses on far rear area care and delayed return to duty, missing the broader aspects of health support and protection.

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