Nursing Elites

1. During a home visit, the nurse observes that a client with limited mobility has difficulty accessing the bathroom. What should the nurse do first?

• A. suggest the client install a bedside commode
• B. assist the client in modifying the home environment
• C. refer the client to an occupational therapist
• D. educate the client on mobility aids

Correct answer: A

Rationale: The correct answer is to suggest that the client installs a bedside commode. This option provides an immediate solution to the client's difficulty accessing the bathroom. While modifying the home environment (Choice B) and referring the client to an occupational therapist (Choice C) are important steps, suggesting a bedside commode addresses the immediate need efficiently. Educating the client on mobility aids (Choice D) can be beneficial but may not be the most urgent action required in this scenario.

2. What information should the nurse provide a client who has undergone cryosurgery for stage 1A cervical cancer?

• A. Expect heavy, watery vaginal discharge for 3 to 6 weeks.
• B. Use a tampon instead of a sanitary napkin.
• C. Report any severe cramping immediately.
• D. Avoid sexual intercourse for 3 to 6 weeks.

Correct answer: D

Rationale: After cryosurgery for stage 1A cervical cancer, clients should avoid sexual intercourse for 3 to 6 weeks to reduce the risk of infection. Heavy, watery vaginal discharge is expected but not the focus of post-procedure instructions. Using tampons is contraindicated as they can introduce bacteria into the healing cervix. While reporting severe cramping is important, avoiding sexual intercourse is the priority to prevent complications.

3. To prepare a presentation on the greatest health concern facing the city, how should the health nurse begin collecting data?

• A. Review morbidity data for the city's population compiled by the Bureau of Vital Statistics
• B. Conduct a random telephone survey to determine the public's perception about health problems
• C. Survey major hospitals in the area to determine the most common reasons for admissions
• D. Call American Medical Association members to determine the most frequently treated diagnoses

Correct answer: A

Rationale: The correct answer is to review morbidity data for the city's population compiled by the Bureau of Vital Statistics. Morbidity data provides detailed and accurate information on the health issues prevalent in the city's population. This data is essential as it reflects actual health conditions rather than perceptions or specific hospital data. Conducting a telephone survey (choice B) may provide subjective opinions rather than objective data. Surveying hospitals (choice C) may only capture data on hospitalized cases and may not represent the entire population. Contacting American Medical Association members (choice D) may provide insights into medical treatments but may not reflect the overall health concerns of the city's population.

4. A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?

• A. Blood pressure of 180/100 mm Hg.
• B. Urine output of 50 mL in 4 hours.
• C. Heart rate of 100 beats per minute.
• D. Nausea and vomiting.

Correct answer: B

Rationale: Urine output of 50 mL in 4 hours indicates oliguria, which can be a sign of worsening renal function and requires immediate intervention. In acute renal failure, maintaining adequate urine output is crucial to prevent further kidney damage and manage fluid balance. A high blood pressure reading (Option A) is concerning but may not require immediate intervention in this scenario as it could be due to the history of hypertension. A heart rate of 100 beats per minute (Option C) is slightly elevated but may not be the most critical finding at this moment. Nausea and vomiting (Option D) are important to assess but are not as urgent as addressing oliguria in a client with acute renal failure.

5. The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?

• A. Apical pulse of 58 beats per minute.
• B. Serum potassium level of 3.0 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Client reports seeing halos around lights.

Correct answer: D

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.

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