Nursing Elites

1. 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.

2. 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.

3. A public health nurse is planning a campaign to increase immunization rates among children in a low-income community. Which intervention should the nurse prioritize?

• A. Provide free immunizations at local schools
• B. Create educational materials about vaccine safety
• C. Organize a community forum to discuss immunization concerns
• D. Partner with local media to promote the importance of vaccines

Correct answer: A

Rationale: The correct answer is A: Provide free immunizations at local schools. This intervention directly addresses financial barriers and increases accessibility for families in low-income communities. By offering free immunizations at local schools, the nurse can ensure that more children receive the necessary vaccines without worrying about the cost. Choice B, creating educational materials, may be helpful but may not directly address the financial barriers that low-income families face. Choice C, organizing a community forum, can be beneficial for addressing concerns but may not result in immediate action to increase immunization rates. Choice D, partnering with local media, can help raise awareness but may not directly provide the solution of making immunizations more accessible by removing financial barriers.

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

• A. Epigastric tenderness.
• B. Bowel sounds are hypoactive.
• C. The client reports sudden, severe abdominal pain.
• D. Bowel sounds are hyperactive.

Correct answer: C

Rationale: The correct answer is C. Sudden, severe abdominal pain can indicate a perforated ulcer, which is a medical emergency requiring immediate intervention. Epigastric tenderness (choice A) may be expected in a client with peptic ulcer disease but does not necessarily require immediate intervention. Hypoactive bowel sounds (choice B) are concerning but not as urgent as sudden, severe abdominal pain. Hyperactive bowel sounds (choice D) are more indicative of conditions like gastroenteritis rather than a perforated ulcer, making it a less critical finding compared to sudden, severe abdominal pain.

5. A nurse has started a group for senior citizens in a church setting. The group decides that their first project will be to begin a program for home-bound members. Which program outcome is the best measure of the project's effectiveness?

• A. number of home-bound seniors who are visited
• B. number of church members who are over 65
• C. average annual income for the homebound members
• D. calls received showing interest in the program

Correct answer: A

Rationale: The number of home-bound seniors visited is the best measure of the project's effectiveness as it directly reflects the reach and impact of the program. Choice B is incorrect as it does not directly relate to the effectiveness of the program for home-bound seniors. Choice C is irrelevant as the average annual income of home-bound members is not a direct measure of the program's effectiveness. Choice D, calls showing interest, is not as direct a measure as the actual visits to the home-bound seniors.

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