Nursing Elites

1. A client with hypertension is being seen in a community clinic. The nurse notes that the client has not been taking their prescribed medication regularly. What is the most appropriate initial intervention?

• A. Educate the client on the importance of medication adherence
• B. Explore the reasons for non-adherence with the client
• C. Refer the client to a hypertension specialist
• D. Adjust the client's medication regimen

Correct answer: B

Rationale: The most appropriate initial intervention when a client is not adhering to prescribed medication is to explore the reasons for non-adherence with the client. Understanding the client's perspective can help identify barriers to adherence, such as side effects, cost, forgetfulness, or misunderstanding of the treatment. By addressing these reasons, the nurse can work collaboratively with the client to develop strategies to improve medication compliance. Educating the client on the importance of adherence (Choice A) may be necessary but should come after exploring the reasons for non-adherence. Referring the client to a hypertension specialist (Choice C) or adjusting the medication regimen (Choice D) should be considered after addressing the underlying reasons for non-adherence.

2. The nurse is assisting with the triage of clients at a large community disaster and finds a man lying on the ground, who states that the blast threw him out of a second-story window. Which action should the nurse implement first?

• A. Logroll the client to his side and assess for back injuries
• B. Perform a complete neurological assessment
• C. Open the client's airway immediately
• D. Place the nurse's hands around the client's neck to stabilize

Correct answer: C

Rationale: Opening the client's airway immediately is the priority in this scenario. Ensuring the airway is clear takes precedence over other actions as it is crucial for the client's breathing and oxygenation. Logrolling the client to assess for back injuries may worsen the condition if there are spinal injuries, so this should not be done as the first step. Performing a complete neurological assessment is important but not the immediate priority over ensuring the airway is clear. Placing the nurse's hands around the client's neck to stabilize is incorrect and could potentially harm the client, as neck stabilization should only be done if there is a suspected neck injury, which is not indicated in this case.

3. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?

• A. notify her parents
• B. refer her for prenatal care
• C. teach breastfeeding methods
• D. offer nutritional instructions

Correct answer: B

Rationale: The correct answer is to refer her for prenatal care. Prenatal care is essential to monitor the health of both the mother and the fetus during pregnancy. While notifying her parents may be important for support and involvement, the priority is ensuring the adolescent receives medical care. Teaching breastfeeding methods and offering nutritional instructions are important but are not the immediate priority in this situation where prenatal care is urgently needed.

4. A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

• A. Continue the heparin infusion as prescribed.
• B. Decrease the heparin infusion rate.
• C. Increase the heparin infusion rate.
• D. Stop the heparin infusion and notify the healthcare provider.

Correct answer: D

Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.

5. A community health nurse is developing a program to reduce the incidence of teen pregnancy. Which strategy is most likely to be effective?

• A. Distribute free condoms at local high schools
• B. Offer comprehensive sex education classes
• C. Promote abstinence-only education
• D. Provide access to reproductive health services

Correct answer: B

Rationale: Comprehensive sex education has been shown to be more effective in reducing teen pregnancy rates compared to abstinence-only education. Providing comprehensive sex education equips teens with knowledge about safe sex practices, contraception methods, and healthy relationships, which empowers them to make informed decisions. Distributing free condoms and providing access to reproductive health services are important components, but without proper education, teens may not understand how to use these resources effectively. Promoting abstinence-only education limits information and may not address the reality of teen sexual behavior, potentially leading to higher pregnancy rates.

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