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The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
- A. Assess the client's vital signs
- B. Start an IV with an 18-gauge needle
- C. Begin iced saline lavage
- D. A, B
Correct Answer: D
Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client's vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.
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When palpating the client's neck for lymphadenopathy, where should the nurse position himself?
- A. At the client's back
- B. At the client's right side
- C. At the client's left side
- D. In front of a sitting client
Correct Answer: D
Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.
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.
The nurse is caring for the client one 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 an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.
Which 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: Corrected Rationale: Insulinomas lead to excessive insulin production, causing hypoglycemia. Symptoms of hypoglycemia include nervousness, jitteriness, and diaphoresis. These symptoms result from the low blood sugar levels. Flushed skin, dry mouth, and tented skin turgor (choice B) are more indicative of dehydration. Polyuria, polydipsia, and polyphagia (choice C) are classic symptoms of diabetes mellitus, not insulinomas. Hypertension, tachycardia, and feeling hot (choice D) are not typical symptoms of insulinomas.
When a field medical element is not operational, it engages in training to achieve readiness for mobilization that involves all aspects of operation. Individuals must be proficient in their MOS/ASI and which of the following?
- A. Command and control procedures
- B. Computers and data processing
- C. Common soldier tasks
- D. Communications and automation
Correct Answer: C
Rationale: In the context of field medical training for mobilization, proficiency in common soldier tasks is essential. This includes skills like first aid, navigation, marksmanship, and other fundamental military tasks. While command and control procedures, communications, and automation are important, common soldier tasks are specifically mentioned in the scenario as critical for achieving readiness and mobilization.