Nursing Elites

1. A home health nurse is reviewing the laboratory results for several clients with heart failure. Which client finding would the nurse report to the health care provider immediately?

• A. Total cholesterol 190
• B. Glycosylated hemoglobin of 7%
• C. B-type natriuretic peptide 550 pg/ml (more than 100 is concerning)
• D. Potassium 3.7

Correct answer: C

Rationale: An elevated B-type natriuretic peptide level indicates worsening heart failure, requiring immediate attention. This biomarker reflects the severity of heart failure and helps guide treatment decisions. Total cholesterol and glycosylated hemoglobin are important for assessing cardiovascular risk and diabetes management but are not indicative of acute heart failure exacerbation. A potassium level of 3.7 falls within the normal range and does not suggest an immediate concern in the context of heart failure.

2. A female client with a history of chronic obstructive pulmonary disease (COPD) is being treated at home and is currently receiving oxygen at 2 liters via nasal cannula. The spouse, who is the caregiver, reports that the client requires assistance when ambulating short distances, including going to the bathroom. Which suggestion should the health care nurse provide to the caregiver?

• A. disconnect oxygen when ambulating to the bathroom
• B. administer a breathing treatment prior to ambulation
• C. suggest obtaining a bedside commode for toileting
• D. ask for additional assistance to reduce the risk of falls

Correct answer: C

Rationale: For a client with COPD requiring assistance for short-distance ambulation, suggesting a bedside commode for toileting is the most appropriate intervention. This recommendation helps reduce the need for the client to walk long distances, thereby minimizing the risk of exertion and potential falls. Disconnecting oxygen during ambulation (Choice A) is not safe for a client with COPD, as oxygen therapy should be continuous. Administering a breathing treatment before ambulation (Choice B) may not directly address the client's need for assistance with toileting. Asking for additional assistance (Choice D) can be beneficial but providing a bedside commode specifically addresses the current issue of ambulating short distances for toileting.

3. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?

• A. annual flu vaccination status
• B. weight and height measurement
• C. total cholesterol level
• D. long bone deformity testing

Correct answer: B

Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.

4. The healthcare provider is inspecting the external eye structures of a client. Which finding is a normal racial variation?

• A. Blue sclerae.
• B. Brown macules on the sclerae.
• C. Slightly yellow sclerae in an African-American client.
• D. Conjunctival pallor.

Correct answer: C

Rationale: The slightly yellow color of the sclera is a normal racial variation found in the African-American population. Blue sclerae (Choice A) are associated with osteogenesis imperfecta, not a normal racial variation. Brown macules on the sclerae (Choice B) may indicate issues like melanoma or melanosis but are not a normal racial variation. Conjunctival pallor (Choice D) suggests anemia or decreased blood flow but is not a normal racial variation.

5. A client with a history of hypertension is admitted with a blood pressure of 180/110 mm Hg. Which medication should the nurse prepare to administer?

• A. Atenolol (Tenormin)
• B. Nifedipine (Procardia)
• C. Hydrochlorothiazide (Microzide)
• D. Clonidine (Catapres)

Correct answer: D

Rationale: In this scenario of severe hypertension (180/110 mm Hg), the nurse should prepare to administer Clonidine (Catapres), which is an antihypertensive medication commonly used to rapidly lower blood pressure in acute situations. Atenolol and Nifedipine are also antihypertensive medications, but Clonidine is more appropriate for immediate blood pressure reduction in this critical situation. Hydrochlorothiazide is a diuretic often used for long-term management of hypertension, not for rapid lowering of severely elevated blood pressure.

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