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. During a home health visit, the nurse notices that an older male client with type 2 diabetes mellitus is wearing loose cloth slippers. The client reports that he cannot comfortably wear other shoes because his toenails get in the way. The nurse inspects the client's feet and finds long thick nails that curl down under some of the toes. Which action should the nurse take?

• A. demonstrate proper foot care to the client and family
• B. have a home health aide assist the client with hygiene weekly
• C. schedule an appointment for the client with a podiatrist
• D. trim the client's toenails gradually over several visits

Correct answer: C

Rationale: Scheduling an appointment with a podiatrist is the most appropriate action in this scenario. For a client with long thick nails that curl under the toes, professional foot care by a podiatrist is necessary to prevent complications, especially in a client with diabetes mellitus. Demonstrating proper foot care (choice A) may not address the immediate need for nail trimming. Having a home health aide assist with hygiene weekly (choice B) may not be sufficient for managing the client's toenail issue effectively. Trimming the client's toenails gradually over several visits (choice D) should be performed by a professional like a podiatrist to avoid potential complications.

3. A community health nurse is conducting a neighborhood discussion group about disaster planning. What information regarding transmission of anthrax should the nurse provide to the group?

• A. Infection is acquired when anthrax spores enter a host.
• B. Mature anthrax bacteria live dormant on inanimate objects.
• C. Spores cannot survive for extended periods outside a living host.
• D. Anthrax is transmitted by respiratory droplets from person to person.

Correct answer: A

Rationale: The correct answer is A: Infection is acquired when anthrax spores enter a host. Anthrax is primarily transmitted through spores entering the body, either through the skin, inhalation, or ingestion. Person-to-person transmission of anthrax is extremely rare and not a significant mode of transmission. Choices B and C are incorrect because mature anthrax bacteria do not live dormant on inanimate objects, and spores can survive for extended periods outside a living host. Choice D is incorrect as anthrax is not transmitted by respiratory droplets from person to person.

4. A client with a history of peptic ulcer disease is admitted with sudden severe abdominal pain. Which finding indicates the possibility of a perforated ulcer?

• A. Bowel sounds are hyperactive in all quadrants.
• B. Abdomen is soft and nondistended.
• C. The client reports sudden severe abdominal pain.
• D. Blood pressure of 110/70 mm Hg.

Correct answer: C

Rationale: The correct answer is C. Sudden severe abdominal pain is a key clinical manifestation of a perforated ulcer. The sudden onset of severe pain is concerning for a perforation in the ulcer, which can lead to peritonitis if not promptly addressed. Choices A, B, and D are incorrect because hyperactive bowel sounds, a soft and nondistended abdomen, and a blood pressure of 110/70 mm Hg are not specific indicators of a perforated ulcer. Hyperactive bowel sounds may suggest increased gastrointestinal motility, a soft abdomen may not necessarily indicate a perforation, and a blood pressure of 110/70 mm Hg is within normal limits and does not directly relate to a perforated ulcer.

5. The healthcare provider is conducting a health assessment for a family living in a high-crime area. Which intervention should the healthcare provider prioritize to ensure the family's safety?

• A. providing information on local crime statistics
• B. teaching the family self-defense techniques
• C. helping the family develop a safety plan
• D. encouraging the family to move to a safer neighborhood

Correct answer: C

Rationale: Developing a safety plan is the most appropriate intervention as it helps the family prepare for potential emergencies and enhances their overall sense of security. Providing information on local crime statistics may raise awareness but does not directly address safety planning. Teaching self-defense techniques may have limited effectiveness in a high-crime area where the family may face multiple threats. Encouraging the family to move to a safer neighborhood is not always feasible due to various reasons such as financial constraints or social ties to the current community.

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