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A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
- A. Measuring and recording fluid intake and output
- B. Weighing the client daily at the same time each day
- C. Assessing the client's vital signs every 4 hours
- D. Checking the client's lungs for crackles during every shift
Correct Answer: B
Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.
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The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?
- A. Encourage the client to drink liquids
- B. Perform active range of motion exercises
- C. Elevate the head of the bed to 45 degrees
- D. Provide a high-fiber diet to the client
Correct Answer: B
Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.
What is the most crucial and most difficult management skill required of the M6 practical nurse?
- A. Preparing time schedules and task assignment rosters
- B. Inspecting equipment for damage and proper function
- C. Preparing reports and maintaining records
- D. Effectively managing personnel
Correct Answer: D
Rationale: Correct. Effectively managing personnel is indeed the most crucial and difficult management skill required of a practical nurse. This skill involves supervising, motivating, and coordinating the work of other healthcare staff, ensuring optimal patient care. Choices A, B, and C are important tasks but do not necessarily involve the same level of complexity and interpersonal skills required for managing personnel in a healthcare setting.
What signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?
- A. Nervousness, jitteriness, and diaphoresis
- B. Flushed skin, dry mouth, and tented skin turgor
- C. Polyuria, polydipsia, polyphagia
- D. Hypertension, tachycardia, and feeling hot
Correct Answer: A
Rationale: The correct answer is A: 'Nervousness, jitteriness, and diaphoresis.' Insulinomas cause hypoglycemia due to excessive insulin production, leading to symptoms such as nervousness (from the sympathetic response to hypoglycemia), jitteriness, and diaphoresis (sweating). Choices B, C, and D are incorrect. Flushed skin, dry mouth, and tented skin turgor (Choice B) are not typical signs of insulinoma. Polyuria, polydipsia, and polyphagia (Choice C) are classic symptoms of diabetes mellitus, not insulinoma. Hypertension, tachycardia, and feeling hot (Choice D) are more indicative of hyperthyroidism or a hypermetabolic state, rather than an insulinoma presentation.
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.
The system used at the division level and forward is comprised of six basic modules. Which module is staffed with two surgeons, two nurse anesthetists, a medical/surgical nurse, two operating room specialists, and two practical nurses?
- A. Treatment squad
- B. Area support squad
- C. Medical service squad
- D. Forward surgical team
Correct Answer: D
Rationale: The correct answer is D, Forward Surgical Team (FST). The FST is indeed staffed with two surgeons, two nurse anesthetists, a medical/surgical nurse, two operating room specialists, and two practical nurses. This team is specifically trained and equipped to provide surgical intervention in austere environments where immediate medical care is needed. Choices A, B, and C do not match the personnel composition described in the question, making them incorrect. The Treatment squad typically focuses on patient care and recovery, the Area support squad provides logistical and administrative support, and the Medical service squad deals with broader medical services beyond surgical interventions.