Nursing Elites

1. 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.

2. A client with a history of peptic ulcer disease is admitted with severe epigastric pain. Which finding requires immediate intervention?

• A. Nausea and vomiting.
• B. Hematemesis.
• C. Melena.
• D. Rebound tenderness.

Correct answer: D

Rationale: In a client with a history of peptic ulcer disease presenting with severe epigastric pain, the finding that requires immediate intervention is rebound tenderness. Rebound tenderness can indicate peritonitis, a serious condition that necessitates immediate medical attention. Nausea and vomiting, hematemesis, and melena are also concerning symptoms in a client with a history of peptic ulcer disease, but they do not signify the urgency of intervention as rebound tenderness does.

3. During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?

• A. report the findings to adult protective services
• B. ask the client how she got the bruises
• C. document the observations in the client's medical record
• D. discuss the observations with the caregiver

Correct answer: B

Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.

4. The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2020 objectives are being addressed?

• A. the absenteeism rate has increased greatly over the past two years
• B. during the last year fewer firearms were retrieved on school property
• C. the number of requests for pregnancy testing is higher than last year
• D. decline in the number of students enrolled in school during the year

Correct answer: B

Rationale: The correct answer is B. A decrease in firearms retrieved on school property is a positive indication that the Healthy People 2020 objectives are being addressed. This finding suggests progress in reducing violence and improving safety in schools, which aligns with the goals of promoting overall health and safety among adolescents. Choices A, C, and D do not directly relate to the Healthy People 2020 objectives. Increased absenteeism, higher requests for pregnancy testing, and a decline in student enrollment do not necessarily reflect the specific health and safety goals outlined in Healthy People 2020.

5. The healthcare professional is developing a safety program for older adults at a senior center. Which topic should the professional prioritize?

• A. medication management
• B. fall prevention
• C. fire safety
• D. emergency preparedness

Correct answer: B

Rationale: Fall prevention should be prioritized for older adults as falls are a significant cause of injury and hospitalization in this population. Addressing fall prevention measures can help reduce the risk of falls and improve the overall safety and well-being of older adults. Medication management, fire safety, and emergency preparedness are also important topics, but fall prevention takes precedence due to its direct impact on the health and safety of older adults.

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