Nursing Elites

1. 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.

2. The healthcare professional is developing a program to educate parents on the importance of immunizations. Which topic should be prioritized?

• A. the benefits of immunizations
• B. the potential side effects of vaccines
• C. the immunization schedule
• D. ways to comfort children during vaccinations

Correct answer: A

Rationale: Prioritizing the benefits of immunizations is crucial in helping parents comprehend the significance of vaccines in safeguarding their children against preventable diseases. Understanding the positive impact of immunizations can alleviate concerns and misconceptions that parents may have, ultimately encouraging them to make informed decisions regarding their children's health. Discussing potential side effects (choice B) is important but should come after highlighting the benefits to avoid instilling unnecessary fear. While the immunization schedule (choice C) is essential information, it may be overwhelming if presented as the initial focus. Comforting children during vaccinations (choice D) is valuable but secondary to ensuring parents understand the benefits of immunizations.

3. The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?

• A. Blood pressure of 160/90 mm Hg.
• B. Blood glucose level of 180 mg/dL.
• C. Difficulty speaking.
• D. Temperature of 99.8°F (37.7°C).

Correct answer: C

Rationale: Difficulty speaking is a classic symptom of a stroke, indicating a potential blockage of blood flow to the brain. Immediate intervention is crucial to minimize brain damage. While an elevated blood pressure (Choice A) may need management, it is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) falls within the normal range and is not a critical finding in this context.

4. During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?

• A. report the findings to adult protective services
• B. ask the client how she got the bruises
• C. document the observations in the client's medical record
• D. discuss the observations with the caregiver

Correct answer: B

Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.

5. The nurse is planning a health education program for 10-year-olds. Which setting is most likely to increase the preadolescents' participation in the program?

• A. the school classroom
• B. community center
• C. home of one of the children
• D. a local place of worship

Correct answer: A

Rationale: The school classroom is the most suitable setting to increase preadolescents' participation in a health education program. At the age of 10, children are accustomed to the school environment, making it familiar and comfortable for them. This familiarity can help reduce anxiety and increase engagement during the program. Community centers may be less familiar and could pose distractions, potentially reducing participation. Conducting the program at the home of one of the children may lead to unequal access for other participants and may not provide the necessary facilities for an educational session. A local place of worship may not be perceived as a neutral or suitable environment for a health education program, potentially hindering participation.

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