Nursing Elites

1. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?

• A. Report of back pain associated with twisting at the waist
• B. Absence of a dental health provider
• C. Lives in a home with 25 other migrant workers
• D. Report of muscle twitching and skin rash

Correct answer: D

Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.

2. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

• A. Demonstrate how to use the spirometer
• B. Set a realistic postoperative goal
• C. Determine the reasons why the client is refusing
• D. Request that a respiratory therapist discuss the technique

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

3. A newly licensed nurse is giving a change-of-shift report using I-SBAR to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the 'Background' portion of the report?

• A. The client has a new prescription for incentive spirometry
• B. The client's partner plans to return later today
• C. The client has no living family members
• D. I initiated a consultation with a nutritionist

Correct answer: C

Rationale: In the 'Background' portion of the report, the nurse should include relevant historical information about the client, such as the fact that the client has no living family members. This information helps provide a more comprehensive understanding of the client's situation. Choices A, B, and D are not typically included in the 'Background' section as they do not pertain to the client's history or background.

4. Which nursing action is essential when administering a blood transfusion?

• A. Ensure the blood is administered within 4 hours.
• B. Check the patient's vital signs every 30 minutes during the transfusion.
• C. Administer the transfusion at a slow rate for the first 15 minutes.
• D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

5. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?

• A. Encourage the patient to take deep breaths.
• B. Assist the patient to sit down slowly.
• C. Instruct the patient to use a walker for support.
• D. Teach the patient how to change positions safely.

Correct answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

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