Nursing Elites

1. A client with a history of diabetes mellitus is admitted with hypoglycemia. Which finding requires immediate intervention?

• A. Blood glucose of 60 mg/dL.
• B. Heart rate of 100 beats per minute.
• C. Tremors.
• D. Diaphoresis.

Correct answer: C

Rationale: In a client with a history of diabetes mellitus admitted with hypoglycemia, the finding that requires immediate intervention is tremors. Tremors can indicate severe hypoglycemia, which needs prompt attention to prevent complications such as seizures or loss of consciousness. While a blood glucose level of 60 mg/dL is low, the presence of tremors signifies a more urgent situation. A heart rate of 100 beats per minute and diaphoresis are common physiological responses to hypoglycemia and do not necessarily require immediate intervention unless other severe symptoms are present.

2. A client with a history of heart failure is admitted with pulmonary edema. Which finding requires immediate intervention?

• A. Peripheral edema.
• B. Oxygen saturation of 88%.
• C. Jugular vein distention.
• D. Productive cough with pink, frothy sputum.

Correct answer: D

Rationale: A productive cough with pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. This finding requires immediate intervention to prevent respiratory compromise and worsening of the condition. Peripheral edema (Choice A) is a manifestation of heart failure but is not as urgent as addressing pulmonary edema. Oxygen saturation of 88% (Choice B) is low and requires attention, but the pink, frothy sputum signifies acute respiratory distress. Jugular vein distention (Choice C) can be seen in heart failure, but the immediate concern in this scenario is addressing the pulmonary edema to ensure adequate gas exchange and oxygenation.

3. The community health nurse is planning a series of educational courses about the healthcare system and meeting healthcare needs for the community center. Which adjunct issue should the nurse address for a group of older adults?

• A. peer concerns
• B. adult daycare
• C. retirement issues
• D. vocational concerns

Correct answer: C

Rationale: Retirement often brings specific healthcare needs and concerns that are crucial to address for older adults. While peer concerns and adult daycare could be important aspects to consider, retirement issues are more directly related to the unique healthcare needs and challenges faced by older adults. Vocational concerns are typically more relevant to individuals who are still actively engaged in the workforce, rather than retired older adults.

4. A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?

• A. Wear a gown and gloves.
• B. Have the client wear a mask.
• C. Perform hand hygiene.
• D. Assign the client to a negative air-flow room.

Correct answer: D

Rationale: The correct answer is to assign the client to a negative air-flow room (Choice D). Active tuberculosis requires implementation of airborne precautions, including isolating the client in a negative pressure air-flow room to prevent the spread of the infection to others. Choice A (Wear a gown and gloves) is important for standard precautions but does not address the specific airborne precautions needed for tuberculosis. Choice B (Have the client wear a mask) may help reduce the spread of respiratory droplets but does not provide adequate protection for healthcare workers or other patients. Choice C (Perform hand hygiene) is essential for infection control but is not the most critical action when dealing with an airborne infection like tuberculosis.

5. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to it. What level of prevention has the nurse applied in this situation?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: A

Rationale: The nurse has applied primary prevention in this situation. Primary prevention involves efforts to prevent the occurrence of domestic violence before it starts, even if the client does not admit to the abuse. Secondary prevention focuses on early detection and intervention to reduce the harm caused by violence that is already occurring. Tertiary prevention involves actions taken to rehabilitate and support individuals who have experienced domestic violence. Health promotion encompasses a broader approach aimed at improving overall health and well-being, which may include education on domestic violence prevention but is not specific to this scenario.

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