Nursing Elites

1. The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?

• A. evaluating a pressure sore
• B. applying a prosthetic device
• C. performing a sterile dressing change
• D. assessing the client's need for an elevated toilet seat

Correct answer: B

Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.

2. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Blood glucose of 250 mg/dL.

Correct answer: D

Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.

3. A community health nurse is conducting a needs assessment in a rural area. Which data source is most likely to provide comprehensive information about the community's health status?

• A. Focus groups with community members
• B. Local hospital admission records
• C. State health department reports
• D. Surveys conducted by healthcare providers

Correct answer: C

Rationale: State health department reports are the most likely data source to provide comprehensive information about the community's health status. These reports offer a broad overview of health statistics and trends that can guide community health interventions. Focus groups with community members, although valuable for gathering qualitative insights, may not provide comprehensive health status data. Local hospital admission records are limited to specific healthcare utilization data and do not capture the overall health status of the entire community. Surveys conducted by healthcare providers may offer some insights but may not provide the breadth and depth of information available in state health department reports.

4. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

• A. Facial weakness and difficulty speaking.
• B. Decreased deep tendon reflexes in the legs.
• C. Inability to move the eyes.
• D. Respiratory distress and cyanosis.

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

5. The healthcare provider is assessing a client with a suspected pulmonary embolism. Which finding requires immediate intervention?

• A. Chest pain.
• B. Shortness of breath.
• C. Tachycardia.
• D. Cyanosis.

Correct answer: D

Rationale: Cyanosis is a late sign of hypoxemia and indicates severe oxygen deprivation, necessitating immediate intervention in a client with a suspected pulmonary embolism. Chest pain, shortness of breath, and tachycardia are also concerning symptoms in pulmonary embolism; however, cyanosis signifies critical oxygen deficiency and warrants urgent attention to prevent further complications.

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