Nokea
The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse's priority intervention?
- A. Escort the client to the physical therapy department
- B. Medicate the client 30 minutes before going to the whirlpool
- C. Obtain the sterile dressing supplies for the client
- D. Assist the client to the bathroom prior to the treatment
Correct Answer: B
Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client's comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (choice A) is not the priority at this time. While obtaining sterile dressing supplies (choice C) is important, ensuring pain management takes precedence. Assisting the client to the bathroom (choice D) is not directly related to the priority intervention of pain management before the whirlpool treatment.
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Under the health services support area concept, how is the medical care under the MEDCOM divided?
- A. Six geographical regions of the United States with command authority in each region
- B. Five levels of health service support, each providing different levels of health care services
- C. Primary and secondary health care regions, each containing a MEDDAC or MEDCEN
- D. Eight geographical areas of responsibility designated as health services support regions, each of which is subdivided into two or more health service areas
Correct Answer: D
Rationale: The correct answer is D. Under the health services support area concept, medical care under MEDCOM is divided into eight geographical areas of responsibility. Each of these areas is designated as a health services support region, and they are further subdivided into two or more health service areas. Choices A, B, and C are incorrect because they do not accurately describe how the medical care under MEDCOM is divided.
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
- A. Pulmonary embolism
- B. Decreased urine output
- C. Hemoptysis
- D. Deep vein thrombosis
Correct Answer: B
Rationale: The correct answer is B: Decreased urine output. When vegetative lesions from the mitral valve embolize, they can block blood flow to the kidneys, leading to renal infarction. This can result in decreased urine output. Choices A, C, and D are incorrect. Pulmonary embolism involves a blockage of an artery in the lungs, not directly related to embolization from the mitral valve. Hemoptysis is the coughing up of blood from the respiratory tract, which is not a direct consequence of embolization from the mitral valve. Deep vein thrombosis is the formation of a blood clot in a deep vein, unrelated to embolization from the mitral valve.
Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?
- A. "Has your child had any sore throats?"
- B. "Has your child been eating properly?"
- C. "Is your child allergic to any antibiotics?"
- D. "Has your child been exposed to any infections?"
Correct Answer: C
Rationale: The correct question the nurse should ask the mother before administering an MMR vaccine to a 15-month-old is whether the child is allergic to any antibiotics. This is crucial because vaccines like MMR contain components that the child could be allergic to, such as neomycin. Checking for antibiotic allergies is essential to prevent adverse reactions to the vaccine. The other options are less relevant in this context. Asking about sore throats, eating habits, or exposure to infections does not directly impact the administration of the MMR vaccine.
The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?
- A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL
- B. Client with diabetes mellitus and a glycosylated hemoglobin A1c (HbA1c) of 7.0%
- C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL
- D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%
Correct Answer: B
Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Choice A, chronic kidney disease with a serum creatinine of 1.6 mg/dL, though concerning, does not indicate an immediate need for follow-up. Choice C, heart failure with a BNP of 140 pg/mL, may require monitoring but not immediate follow-up. Choice D, a male client with anemia and normal hemoglobin and hematocrit levels, does not warrant immediate attention based on the provided information.
In which situation(s) does the nurse act as a client advocate?
- A. Pulling the curtain around the client's bed while changing a dressing
- B. Contacting the health care provider to request a meeting for the client
- C. Ensuring access to medical information by appropriate personnel only
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all the situations listed reflect aspects of client advocacy. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity for the client, which is an essential part of advocacy. Contacting the health care provider to request a meeting for the client involves advocating for the client's needs and preferences. Ensuring access to medical information by appropriate personnel only is another way the nurse advocates for the client by safeguarding their confidentiality and promoting proper communication. Choices A, B, and C all demonstrate different aspects of advocacy, making option D the correct choice.