Nursing Elites

1. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?

• A. Epigastric tenderness.
• B. Bowel sounds are hypoactive.
• C. The client reports sudden, severe abdominal pain.
• D. Bowel sounds are hyperactive.

Correct answer: C

Rationale: The correct answer is C. Sudden, severe abdominal pain can indicate a perforated ulcer, which is a medical emergency requiring immediate intervention. Epigastric tenderness (choice A) may be expected in a client with peptic ulcer disease but does not necessarily require immediate intervention. Hypoactive bowel sounds (choice B) are concerning but not as urgent as sudden, severe abdominal pain. Hyperactive bowel sounds (choice D) are more indicative of conditions like gastroenteritis rather than a perforated ulcer, making it a less critical finding compared to sudden, severe abdominal pain.

2. The healthcare provider is planning a health education session for teenagers on the importance of physical activity. Which strategy is most likely to be effective?

• A. lecturing about the benefits of physical activity
• B. showing videos of athletes
• C. organizing interactive physical activities
• D. distributing pamphlets on physical fitness

Correct answer: C

Rationale: Organizing interactive physical activities is the most effective strategy for educating teenagers on the importance of physical activity. This approach engages the teenagers actively, making the learning experience more enjoyable and memorable. Lecturing (choice A) may not be as engaging for teenagers, potentially leading to disinterest. Showing videos of athletes (choice B) may capture attention momentarily but may not have a lasting impact on understanding the importance of physical activity. Distributing pamphlets (choice D) is a passive method that may not effectively convey the message or engage teenagers in a meaningful way.

3. The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2020 objectives are being addressed?

• A. the absenteeism rate has increased greatly over the past two years
• B. during the last year fewer firearms were retrieved on school property
• C. the number of requests for pregnancy testing is higher than last year
• D. decline in the number of students enrolled in school during the year

Correct answer: B

Rationale: The correct answer is B. A decrease in firearms retrieved on school property is a positive indication that the Healthy People 2020 objectives are being addressed. This finding suggests progress in reducing violence and improving safety in schools, which aligns with the goals of promoting overall health and safety among adolescents. Choices A, C, and D do not directly relate to the Healthy People 2020 objectives. Increased absenteeism, higher requests for pregnancy testing, and a decline in student enrollment do not necessarily reflect the specific health and safety goals outlined in Healthy People 2020.

4. 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.

5. The nurse is preparing to administer a scheduled dose of digoxin (Lanoxin) to a client. Which assessment finding should the nurse report to the healthcare provider?

• A. Heart rate of 90 beats per minute.
• B. Serum potassium level of 4.0 mEq/L.
• C. Blood pressure of 130/80 mm Hg.
• D. Client reports seeing halos around lights.

Correct answer: D

Rationale: Seeing halos around lights is a symptom of digoxin toxicity, which should be reported to the healthcare provider. This visual disturbance is a serious adverse effect of digoxin and indicates potential toxicity. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal limits and do not indicate an immediate need for intervention related to digoxin administration.

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