Nursing Elites

1. A client with a history of heart failure is admitted with severe dyspnea. Which intervention should the nurse implement first?

• A. Administer oxygen at 2 liters per minute via nasal cannula.
• B. Place the client in a high Fowler's position.
• C. Obtain a 12-lead electrocardiogram (ECG).
• D. Administer intravenous furosemide (Lasix).

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position first. This intervention helps improve breathing and oxygenation in clients with severe dyspnea, including those with heart failure. Elevating the head of the bed reduces the work of breathing and enhances lung expansion. Administering oxygen, obtaining an ECG, and administering furosemide are important interventions in the management of heart failure, but placing the client in a high Fowler's position is the priority to address the immediate need for improved breathing and oxygenation.

2. During which home visit performed by a registered nurse or a practical nurse can the home healthcare agency expect Medicare reimbursement for documenting a skilled care service provided?

• A. 13-18 years of age
• B. 11-12 years of age
• C. 18-24 months of age
• D. 4-6 years of age

Correct answer: D

Rationale: The correct answer is D: 4-6 years of age. According to current CDC guidelines, a child receiving the measles, mumps, rubella (MMR) vaccine at 12 months of age should plan to receive the MMR booster between 4-6 years of age. Choices A, B, and C are incorrect as they do not align with the CDC's recommended age range for the MMR vaccine booster. It is crucial for healthcare providers to stay updated with current guidelines to ensure the timely administration of vaccines for optimal protection.

3. A client with a history of alcoholism is admitted with pancreatitis. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Nausea and vomiting.
• B. Epigastric pain radiating to the back.
• C. Temperature of 102°F (38.9°C).
• D. Mild jaundice.

Correct answer: C

Rationale: A temperature of 102°F (38.9°C) is the most important assessment finding to report to the healthcare provider in a client with pancreatitis and a history of alcoholism. Fever in this context can indicate infection, which is a serious complication requiring immediate intervention. Nausea and vomiting (choice A) are common symptoms of pancreatitis but may not require immediate intervention unless severe. Epigastric pain radiating to the back (choice B) is a classic symptom of pancreatitis and should be addressed, but a fever takes precedence. Mild jaundice (choice D) may be present in pancreatitis but is not as urgent as a high temperature signaling possible infection.

4. The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?

• A. Blood glucose level of 150 mg/dL.
• B. Weight gain of 2 pounds in 24 hours.
• C. Decreased urine output.
• D. Temperature of 100.3°F (37.9°C).

Correct answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

5. During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?

• A. Instruct the client to monitor her blood pressure at home
• B. Refer the client to her healthcare provider for further evaluation
• C. Educate the client on lifestyle changes to reduce blood pressure
• D. Recheck the blood pressure in 15 minutes

Correct answer: B

Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.

Similar Questions