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. When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?

• A. Remove the inner cannula.
• B. Clean the stoma with normal saline.
• C. Change the tracheostomy ties.
• D. Suction the tracheostomy.

Correct answer: D

Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.

3. An older adult client visits the community health clinic and reports the onset of pain, redness, and swelling of the right eye. Which question is most important for the clinic nurse to ask the client?

• A. Do you have any discharge from the eye?
• B. Have you started any new prescriptions?
• C. Are all of your immunizations current?
• D. How often do you wash your hands?

Correct answer: B

Rationale: The most important question for the nurse to ask the client is whether they have started any new prescriptions. New medications can have side effects that include eye issues, so it is crucial to determine if there is a potential link. Asking about discharge from the eye (Choice A) may be relevant but does not address the possibility of medication side effects. Inquiring about immunizations (Choice C) and handwashing frequency (Choice D) is important for overall health but is less directly related to the eye symptoms described by the client.

4. While assessing a client receiving a blood transfusion, which finding requires immediate intervention?

• A. Temperature of 100.4°F (38°C).
• B. Blood pressure of 110/70 mm Hg.
• C. Heart rate of 90 beats per minute.
• D. Complaints of feeling cold.

Correct answer: C

Rationale: A heart rate of 90 beats per minute requires immediate intervention when assessing a client receiving a blood transfusion. This finding can indicate a potential transfusion reaction, such as a hemolytic reaction or fluid overload, which requires prompt evaluation and management to prevent serious complications. While a temperature of 100.4°F (38°C) may indicate a mild fever, it is not typically an immediate concern during a blood transfusion. A blood pressure of 110/70 mm Hg is within the normal range and does not necessitate immediate intervention. Complaints of feeling cold can be addressed but do not indicate an urgent need for intervention compared to the critical nature of a potential transfusion reaction indicated by an elevated heart rate.

5. A client with a history of diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which finding requires immediate intervention?

• A. Blood glucose of 200 mg/dL.
• B. Serum bicarbonate of 20 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Urine output of 50 mL in 4 hours.

Correct answer: D

Rationale: In a client with diabetic ketoacidosis (DKA), urine output of 50 mL in 4 hours indicates oliguria, which is a concerning sign of decreased renal perfusion and potential renal failure. This finding requires immediate intervention to prevent further deterioration of kidney function.\n\nChoice A (Blood glucose of 200 mg/dL) is elevated but not the most urgent concern in this scenario. Choice B (Serum bicarbonate of 20 mEq/L) reflects metabolic acidosis, which is expected in DKA but does not require immediate intervention. Choice C (Blood pressure of 140/90 mm Hg) is slightly elevated but not acutely concerning in the context of DKA.

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