Nursing Elites

1. The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?

• A. Clamp the chest tube for 30 minutes every 2 hours.
• B. Milk the chest tube to ensure patency.
• C. Keep the drainage system at the level of the chest.
• D. Ensure that the chest tube is not clamped or kinked.

Correct answer: D

Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.

2. A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply)

• A. age
• B. school dropout
• C. drug addiction
• D. All of the above

Correct answer: D

Rationale: All these factors - age, school dropout, drug addiction - are significant health risk factors for the client. Being young, a high school dropout, and struggling with drug addiction can lead to various complications during pregnancy, such as poor prenatal outcomes and social challenges. These factors can impact the client's overall health and well-being, highlighting the importance of addressing them during prenatal care.

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 client with the sexually transmitted disease HPV reports having had prior sexually transmitted infections. Which response should the nurse provide?

• A. Emphasize that using safe sex practices removes the risk of transmission.
• B. Instruct the client of the importance of notifying sexual partners.
• C. Reassure that complications will not occur if infection is treated.
• D. Provide counseling that most contraceptives prevent against infection.

Correct answer: B

Rationale: Instructing the client about the importance of notifying sexual partners is crucial when dealing with sexually transmitted infections like HPV. This helps prevent the spread of the infection to others and promotes responsible sexual behavior. Choices A, C, and D are incorrect because while using safe sex practices is important, notifying sexual partners is more immediate and directly related to preventing the spread of the infection. Reassuring about complications and discussing contraceptives do not address the immediate need to notify partners.

5. A public health nurse is planning an educational campaign to reduce the incidence of hypertension in the community. Which group should be the primary target of this campaign?

• A. adolescents
• B. young adults
• C. middle-aged adults
• D. older adults

Correct answer: C

Rationale: The correct answer is C, middle-aged adults. Middle-aged adults are at a higher risk for developing hypertension due to lifestyle factors and aging. Targeting this group for preventive measures such as dietary changes, exercise, and stress management can have a significant impact on reducing the incidence of hypertension. Choices A, B, and D are less appropriate targets as adolescents generally have lower rates of hypertension, young adults are less likely to be affected by hypertension at this stage, and older adults may already have established hypertension or comorbidities that could make prevention more challenging.

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