Nursing Elites

1. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Oxygen saturation of 92%.
• C. Temperature of 99°F (37.2°C).
• D. Pain at the surgical site.

Correct answer: C

Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.

2. The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?

• A. Note in the student records that the second dose of the MMR vaccine should be administered prior to entering first grade
• B. Send notices home with the children on the first day of class advising that MMR vaccine series must be completed
• C. Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year
• D. Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children

Correct answer: C

Rationale: The correct intervention for the school nurse is to contact kindergarten parents to remind them that the second dose of the MMR vaccine is due at the start of the school year. This approach directly addresses the issue of incomplete vaccination coverage and ensures that children receive the complete vaccination on time. Choice A is incorrect as it only notes the need for the second dose without actively engaging parents. Choice B is not as effective as directly contacting parents and may lead to delays in completing the vaccination series. Choice D, while promoting immunization, does not directly address the current situation of incomplete MMR vaccination among the kindergarten students.

3. The healthcare provider is caring for a client with diabetes insipidus. Which finding indicates that the treatment is effective?

• A. Urine output is decreased.
• B. Thirst is decreased.
• C. Weight loss is observed.
• D. Urine specific gravity is within the normal range.

Correct answer: D

Rationale: In diabetes insipidus, the body loses excessive amounts of water, leading to diluted urine with low specific gravity. Therefore, when the urine specific gravity is within the normal range, it indicates that the kidneys are properly concentrating urine, which is a sign of effective treatment for diabetes insipidus. Choices A, B, and C are incorrect because in diabetes insipidus, there is polyuria (excessive urination), persistent thirst due to fluid loss, and potential weight loss due to fluid imbalance, so these findings would not indicate effective treatment.

4. When examining sources for funding, which criteria should the nurse clarify about the program for the community group?

• A. a prescription from the healthcare provider for each visit made
• B. documentation of a skilled care service provided during the visit
• C. a copy of the client's health history and social security card
• D. a record of the preventive healthcare services provided during the visit

Correct answer: C

Rationale: The correct answer is C because when seeking funding sources for a community outreach program, it is essential to clarify aspects related to the client's personal information, such as health history and identification details. This information helps in demonstrating the need for the program and understanding the target population. Choices A, B, and D are incorrect because they focus on clinical documentation, services provided during visits, and preventive healthcare services, which are not directly related to clarifying funding criteria about the program.

5. A public health nurse is addressing the issue of childhood lead poisoning in a low-income community. Which intervention should be prioritized?

• A. Providing free blood lead level testing for children
• B. Distributing pamphlets on the dangers of lead exposure
• C. Conducting home inspections for lead-based paint
• D. Educating parents about lead poisoning prevention

Correct answer: A

Rationale: Providing free blood lead level testing for children should be prioritized as it directly identifies children who are at risk and in need of intervention. This intervention allows for early detection and timely implementation of necessary measures to prevent further lead exposure or address existing poisoning. Distributing pamphlets (choice B) may raise awareness but does not directly identify at-risk children. Conducting home inspections (choice C) is important but may not be as immediate and targeted as blood lead level testing. Educating parents (choice D) is essential but may not directly identify and address individual cases of lead poisoning as testing does.

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