Nursing Elites

1. The home health nurse visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who are the caregivers, tell the nurse that their son sleeps most of the time. The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a Duragesic pain patch in place, and skin lesions that are closed and dried. Which intervention should the nurse implement?

• A. remove the Duragesic patch as directed by the prescription
• B. give the client a complete bed bath to further assess the client's condition
• C. discuss end-of-life decisions with the client's parents
• D. call for ambulance transportation to the hospital immediately

Correct answer: C

Rationale: In this scenario, the client with AIDS is showing signs of being in a critical condition - semi-conscious, in pain, and with stable vital signs. The appropriate intervention for the nurse to implement is to discuss end-of-life decisions with the client's parents. Given the client's symptoms, the presence of a pain patch, and the closed and dried skin lesions, it is essential to address end-of-life care planning. Removing the Duragesic patch without proper authorization can lead to inadequate pain management and should not be done without consulting the healthcare provider. Giving a complete bed bath is not the priority in this situation as it does not address the immediate needs of the client. Calling for ambulance transportation to the hospital immediately may not be necessary if the client is stable; instead, the focus should be on providing appropriate support and having critical discussions about the client's care preferences.

2. A client with a history of heart failure is admitted with severe dyspnea. Which intervention should the nurse implement first?

• A. Administer oxygen at 2 liters per minute via nasal cannula.
• B. Place the client in a high Fowler's position.
• C. Obtain a 12-lead electrocardiogram (ECG).
• D. Administer intravenous furosemide (Lasix).

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position first. This intervention helps improve breathing and oxygenation in clients with severe dyspnea, including those with heart failure. Elevating the head of the bed reduces the work of breathing and enhances lung expansion. Administering oxygen, obtaining an ECG, and administering furosemide are important interventions in the management of heart failure, but placing the client in a high Fowler's position is the priority to address the immediate need for improved breathing and oxygenation.

3. The community health nurse is planning a series of educational courses about the healthcare system and meeting healthcare needs for the community center. Which adjunct issue should the nurse address for a group of older adults?

• A. peer concerns
• B. adult daycare
• C. retirement issues
• D. vocational concerns

Correct answer: C

Rationale: Retirement often brings specific healthcare needs and concerns that are crucial to address for older adults. While peer concerns and adult daycare could be important aspects to consider, retirement issues are more directly related to the unique healthcare needs and challenges faced by older adults. Vocational concerns are typically more relevant to individuals who are still actively engaged in the workforce, rather than retired older adults.

4. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

• A. Supine with the foot of the bed raised.
• B. On the left side with legs elevated.
• C. On the right side with legs elevated.
• D. Prone with head elevated.

Correct answer: A

Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.

5. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?

• A. Jaundice.
• B. Ascites.
• C. Peripheral edema.
• D. Spider angiomas.

Correct answer: D

Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.

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