Nursing Elites

1. The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?

• A. Weight gain of 1 pound.
• B. Dizziness.
• C. Fatigue.
• D. Muscle cramps.

Correct answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.

2. A nurse starts classes for clients with type 2 diabetes. Which information would the nurse use as an outcome evaluation for the class?

• A. Parking convenience for attendees continues to be a major concern.
• B. Fasting blood glucose average readings were 20% lower by the end of classes.
• C. Discussion of food exchanges and calories was a well-attended class.
• D. Demonstrating the use of a blood glucose meter was an effective teaching strategy.

Correct answer: B

Rationale: A reduction in fasting blood glucose levels indicates the effectiveness of the diabetes management education provided. Monitoring blood glucose levels is a crucial aspect of diabetes management, and a decrease in average readings signifies improvement in managing blood sugar levels. Choices A, C, and D are not direct outcome evaluations related to the effectiveness of the education provided in managing diabetes. Parking convenience, attendance, and teaching strategies are not direct indicators of the impact on the clients' health outcomes.

3. Which intervention by the community health nurse is an example of a secondary level of prevention?

• A. providing a needle exchange program at a community mental health clinic
• B. developing an educational program for clients with diabetes mellitus
• C. administering influenza vaccines to residents of a nursing home
• D. initiating contact notifications for sexual partners of an HIV client

Correct answer: C

Rationale: Administering influenza vaccines to residents of a nursing home is an example of secondary prevention. Secondary prevention aims to detect and treat a disease or condition in its early stages to prevent complications. In this case, administering influenza vaccines helps prevent the spread of the flu among vulnerable individuals. Choices A, B, and D are not examples of secondary prevention. Providing a needle exchange program (Choice A) is a harm reduction strategy (tertiary prevention). Developing an educational program for clients with diabetes mellitus (Choice B) focuses on health promotion and primary prevention. Initiating contact notifications for sexual partners of an HIV client (Choice D) is a measure to prevent further transmission of the disease but is more aligned with tertiary prevention.

4. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Oxygen saturation of 92%.
• C. Temperature of 99°F (37.2°C).
• D. Pain at the surgical site.

Correct answer: C

Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.

5. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?

• A. Leave a detailed message about the client's condition.
• B. Tell the receptionist to have the healthcare provider return the phone call.
• C. Call another healthcare provider.
• D. Document the attempt to call the healthcare provider.

Correct answer: B

Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.

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