Nursing Elites

1. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

• A. Screening groups of older adults in nursing care facilities for early influenza manifestations
• B. Promoting hand hygiene to prevent the spread of influenza
• C. Administering influenza vaccinations
• D. Educating about the importance of healthy lifestyle choices to prevent influenza

Correct answer: A

Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.

2. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?

• A. pH below 7.3
• B. Potassium of 5.0
• C. HCT of 60
• D. PaO2 of 79%

Correct answer: C

Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.

3. What is the most suitable snack food for the LPN/LVN to offer a client with myasthenia gravis who is at risk for altered nutritional status?

• A. Chocolate pudding.
• B. Graham crackers.
• C. Sugar-free gelatin.
• D. Apple slices.

Correct answer: A

Rationale: Chocolate pudding is the best snack food choice for a client with myasthenia gravis at risk for altered nutritional status due to its nutrient density and soft texture, which can be easier for clients with swallowing difficulties to consume. Graham crackers, sugar-free gelatin, and apple slices may not provide the same level of nutrient density or ease of consumption for these clients. Graham crackers and apple slices may also pose challenges for clients with swallowing difficulties, while sugar-free gelatin, although a good option for some clients, may not offer the same level of nutrition as chocolate pudding.

4. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?

• A. Decreased subcutaneous fat
• B. Muscle atrophy
• C. Pressure injury
• D. Fecal impaction

Correct answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

5. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?

• A. Erythema on pressure points
• B. Lower-extremity pulse strength of 2+
• C. Fluid intake of 3,000 mL per day
• D. A bowel movement every other day

Correct answer: A

Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.

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