Nursing Elites

1. The public health nurse is preparing to administer flu vaccines at a community center. Which group should the nurse prioritize for vaccination?

• A. children under 5 years old
• B. adults aged 50-65
• C. pregnant women
• D. healthcare workers

Correct answer: C

Rationale: Pregnant women should be prioritized for flu vaccination as they are at higher risk for complications from the flu. During pregnancy, changes in the immune, heart, and lung functions make pregnant women more susceptible to severe illness from the flu. Vaccinating pregnant women not only protects them but also provides passive immunity to their newborns. Children under 5, adults aged 50-65, and healthcare workers are important groups for vaccination but do not have the same level of increased risk for flu complications as pregnant women.

2. The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?

• A. Hypertension.
• B. Diabetes mellitus.
• C. Inadequate lifestyle changes in diet and exercise.
• D. Increased risk of chronic illnesses.

Correct answer: C

Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.

3. A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?

• A. Increased respiratory rate.
• B. Absence of breath sounds.
• C. Expiratory wheezes.
• D. Productive cough with green sputum.

Correct answer: B

Rationale: The correct answer is B: Absence of breath sounds. This finding can indicate a pneumothorax or severe asthma exacerbation, both of which require immediate intervention to ensure adequate ventilation and prevent further complications. Increased respiratory rate (choice A) is common in asthma exacerbations but may not always necessitate immediate intervention. Expiratory wheezes (choice C) are typical in asthma and may not always indicate a critical condition. A productive cough with green sputum (choice D) suggests a possible respiratory infection but does not warrant immediate intervention as much as the absence of breath sounds.

4. The healthcare provider is caring for a client with diabetes insipidus. Which finding indicates that the treatment is effective?

• A. Urine output is decreased.
• B. Thirst is decreased.
• C. Weight loss is observed.
• D. Urine specific gravity is within the normal range.

Correct answer: D

Rationale: In diabetes insipidus, the body loses excessive amounts of water, leading to diluted urine with low specific gravity. Therefore, when the urine specific gravity is within the normal range, it indicates that the kidneys are properly concentrating urine, which is a sign of effective treatment for diabetes insipidus. Choices A, B, and C are incorrect because in diabetes insipidus, there is polyuria (excessive urination), persistent thirst due to fluid loss, and potential weight loss due to fluid imbalance, so these findings would not indicate effective treatment.

5. A homeless client with alcohol dependency will be dismissed from the emergency department in 24 hours. The nurse notes that a tuberculin skin test was prescribed by the healthcare provider. What intervention is most important for the nurse to implement prior to discharge?

• A. Identify how the client will follow-up to have the results read
• B. Give the client written information about the tuberculosis test
• C. Determine if the client understands the purpose of the tuberculin test
• D. Explain to the client results should be read between 48 and 72 hours

Correct answer: A

Rationale: The most important intervention for the nurse to implement prior to the discharge of a homeless client with alcohol dependency who had a tuberculin skin test prescribed is to identify how the client will follow-up to have the results read. This is crucial to ensure proper diagnosis and treatment. Providing written information (Choice B) is helpful but not as critical as ensuring the follow-up plan. Determining if the client understands the purpose of the test (Choice C) is important but not as immediate as ensuring the follow-up plan. Explaining when the results should be read (Choice D) is important, but the priority is to make sure the client has a plan in place for follow-up.

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