Nursing Elites

1. A home health nurse is reviewing the laboratory results for several clients with heart failure. Which client finding would the nurse report to the health care provider immediately?

• A. Total cholesterol 190
• B. Glycosylated hemoglobin of 7%
• C. B-type natriuretic peptide 550 pg/ml (more than 100 is concerning)
• D. Potassium 3.7

Correct answer: C

Rationale: An elevated B-type natriuretic peptide level indicates worsening heart failure, requiring immediate attention. This biomarker reflects the severity of heart failure and helps guide treatment decisions. Total cholesterol and glycosylated hemoglobin are important for assessing cardiovascular risk and diabetes management but are not indicative of acute heart failure exacerbation. A potassium level of 3.7 falls within the normal range and does not suggest an immediate concern in the context of heart failure.

2. During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds onto the furniture while refusing any assistance. Which action should the nurse implement?

• A. determine home navigational safety hazards
• B. maintain the client's privacy while in the bathroom
• C. recommend that the client obtain a walker
• D. encourage the client to obtain a medical alert device

Correct answer: A

Rationale: The correct action for the nurse to implement is to determine home navigational safety hazards. In this scenario, the client is unsteady and holds onto furniture while refusing assistance, indicating a risk of falls. By identifying and addressing home safety hazards, the nurse can help prevent potential accidents. Maintaining privacy in the bathroom (Choice B) is important but not the priority in this situation. Recommending a walker (Choice C) or a medical alert device (Choice D) may be appropriate interventions later but addressing home safety hazards is the immediate concern.

3. The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?

• A. Clamp the chest tube for 30 minutes every 2 hours.
• B. Milk the chest tube to ensure patency.
• C. Keep the drainage system at the level of the chest.
• D. Ensure that the chest tube is not clamped or kinked.

Correct answer: D

Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.

4. A client presents at a community-based clinic with complaints of shortness of breath, headache, often uses a gasoline-powered pressure washer to clean equipment and farm buildings. Which type of poisoning is the most likely etiology of this client's symptoms?

• A. asbestos
• B. silica dust
• C. histoplasmosis
• D. carbon monoxide

Correct answer: D

Rationale: The correct answer is D, carbon monoxide poisoning. This client's symptoms of shortness of breath and headache are consistent with carbon monoxide exposure, which can result from using gasoline-powered equipment in poorly ventilated areas. Asbestos (choice A) is linked to respiratory issues but does not typically present with these acute symptoms. Silica dust (choice B) exposure is associated with lung damage, not the symptoms described. Histoplasmosis (choice C) is a fungal infection and would not typically manifest with the symptoms presented by the client.

5. The healthcare professional is developing a program to educate parents on childhood nutrition. Which topic should be prioritized?

• A. the benefits of organic foods
• B. how to read nutrition labels
• C. the importance of a balanced diet
• D. ways to incorporate more vegetables into meals

Correct answer: C

Rationale: Prioritizing the topic of the importance of a balanced diet is crucial as it provides a fundamental understanding for parents to establish healthy eating habits for their children. Understanding the importance of a balanced diet helps parents make informed decisions about food choices, portion sizes, and meal planning. Option A, focusing on the benefits of organic foods, while valuable, may not be feasible or affordable for all families. Option B, teaching parents how to read nutrition labels, is important but secondary to understanding the overall concept of a balanced diet. Option D, discussing ways to incorporate more vegetables into meals, is beneficial but should come after establishing the foundation of a balanced diet.

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