Nursing Elites

1. The nurse identifies a client's needs and formulates the nursing problem of 'Imbalance nutrition: Less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?

• A. Eat 50% of six small meals each day by the end of the week.
• B. Gain 5 pounds by the end of the month.
• C. Have increased caloric intake.
• D. Show improved nutritional status.

Correct answer: A

Rationale: The correct short-term goal for the client in this scenario is option A: 'Eat 50% of six small meals each day by the end of the week.' This goal is specific, measurable, and time-bound, which aligns with the SMART criteria for goal setting in nursing care. It addresses the client's nutritional needs directly, focusing on increasing meal frequency to meet body requirements and counteract weight loss. Option B, 'Gain 5 pounds by the end of the month,' is not as suitable as it lacks specificity and a short-term timeline, making it less achievable within the immediate care plan. Option C, 'Have increased caloric intake,' is vague and does not provide a measurable target for the client to work towards. Option D, 'Show improved nutritional status,' is a broad goal that lacks the specificity needed for effective short-term goal setting in nursing care. Therefore, option A is the most appropriate choice for this client's short-term goal.

2. The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?

• A. Muscle weakness.
• B. Irregular heart rate.
• C. Increased urinary output.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.

3. A client with hypertension is being seen in a community clinic. The nurse notes that the client has not been taking their prescribed medication regularly. What is the most appropriate initial intervention?

• A. Educate the client on the importance of medication adherence
• B. Explore the reasons for non-adherence with the client
• C. Refer the client to a hypertension specialist
• D. Adjust the client's medication regimen

Correct answer: B

Rationale: The most appropriate initial intervention when a client is not adhering to prescribed medication is to explore the reasons for non-adherence with the client. Understanding the client's perspective can help identify barriers to adherence, such as side effects, cost, forgetfulness, or misunderstanding of the treatment. By addressing these reasons, the nurse can work collaboratively with the client to develop strategies to improve medication compliance. Educating the client on the importance of adherence (Choice A) may be necessary but should come after exploring the reasons for non-adherence. Referring the client to a hypertension specialist (Choice C) or adjusting the medication regimen (Choice D) should be considered after addressing the underlying reasons for non-adherence.

4. The nurse obtains a pulse rate of 89 beats/min for an infant before administering digoxin (Lanoxin). What action should the nurse take?

• A. Administer the medication.
• B. Hold the medication and contact the healthcare provider.
• C. Double the dose.
• D. Increase fluid intake.

Correct answer: B

Rationale: The correct answer is to hold the medication and contact the healthcare provider. Bradycardia (pulse rate less than 100 beats/minute) is an early sign of digoxin toxicity. It is essential to withhold digoxin and notify the healthcare provider to prevent potential adverse effects. Administering the medication (Choice A) could exacerbate the toxicity. Doubling the dose (Choice C) is inappropriate and dangerous. Increasing fluid intake (Choice D) is not indicated in this situation and does not address the issue of digoxin toxicity.

5. The public health nurse is called to investigate a report of several cases of chickenpox at a daycare center. The daycare worker states that five children have been sent home over the past two weeks with fever and itchy blisters. Which intervention should the nurse implement first?

• A. Validate that the children sent home did develop chickenpox
• B. Report the presence of a viral endemic at the daycare center
• C. Confirm the number of children with symptoms
• D. Determine how many people have been exposed

Correct answer: A

Rationale: Validating that the children sent home did develop chickenpox is the most crucial initial step for the nurse. This intervention ensures that the appropriate public health measures are implemented for the containment of chickenpox. Reporting a viral endemic or confirming the number of children with symptoms may be important but are secondary to confirming the diagnosis. Determining the number of people exposed comes after confirming the diagnosis to assess the extent of the outbreak and implement necessary control measures.

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