Nursing Elites

1. A community health nurse is addressing the issue of elder abuse in the community. Which intervention should be prioritized?

• A. providing education on the signs of elder abuse
• B. setting up a support group for elder abuse survivors
• C. partnering with local law enforcement to increase patrols
• D. creating a confidential hotline for reporting abuse

Correct answer: D

Rationale: The prioritized intervention for addressing elder abuse in the community should be the creation of a confidential hotline for reporting abuse. A confidential hotline offers a safe and accessible way for individuals to report elder abuse and seek help promptly. Providing education on the signs of elder abuse (Choice A) is important but may not directly address immediate reporting and intervention needs. Setting up a support group for elder abuse survivors (Choice B) is beneficial for emotional support but may not address the primary need for reporting abuse. Partnering with local law enforcement to increase patrols (Choice C) focuses on prevention rather than providing a direct reporting mechanism for victims.

2. 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.

3. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?

• A. Blood glucose of 250 mg/dL.
• B. Serum potassium of 3.5 mEq/L.
• C. Serum sodium of 135 mEq/L.
• D. Arterial blood pH of 7.30.

Correct answer: D

Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.

4. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

5. During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?

• A. Administer a prescribed bronchodilator
• B. Increase the oxygen flow rate
• C. Instruct the client to perform pursed-lip breathing
• D. Notify the healthcare provider immediately

Correct answer: C

Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.

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