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 is coaching a group of high school students on ways to deal with the stress of final exams. Today the class is focusing on healthy food choices for lunch in the school cafeteria. Which option should the nurse recommend?

• A. cheeseburger on a whole wheat bun, French fries, and a large cola beverage
• B. tuna casserole with peas and corn, a fresh apple, crackers, and orange juice
• C. fruit salad with fresh berries and oranges, chicken vegetable soup, and tea
• D. chef salad with turkey, ham, and ranch dressing, apple juice, and milk

Correct answer: C

Rationale: The recommended option for managing stress during final exams is a balanced and nutritious meal. Fruit salad with fresh berries and oranges, chicken vegetable soup, and tea offer a variety of nutrients and antioxidants that can help combat stress. Option A is not ideal as it includes high-fat and high-calorie foods. Option B is a good choice, but Option C provides a wider range of nutrients and hydration. Option D is a healthy choice with a variety of proteins and vitamins, but Option C offers lighter options that may be easier to digest during stressful times.

3. A public health nurse is working with a community to improve access to dental care. Which intervention is most likely to be effective?

• A. Setting up dental clinics in accessible locations
• B. Distributing flyers with information about dental services
• C. Offering transportation vouchers for dental appointments
• D. Partnering with local businesses to promote dental health

Correct answer: A

Rationale: Setting up dental clinics in accessible locations is the most effective intervention to improve access to dental care. By having dental clinics in easily reachable places, community members are more likely to seek and utilize dental services. Distributing flyers may raise awareness, but it may not address the issue of physical accessibility to dental care. Offering transportation vouchers could help with transportation barriers but might not address the core issue of proximity to dental services. Partnering with local businesses to promote dental health is a good initiative, but it may not directly improve access to dental care as setting up clinics in accessible locations would.

4. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?

• A. notify her parents
• B. refer her for prenatal care
• C. teach breastfeeding methods
• D. offer nutritional instructions

Correct answer: B

Rationale: The correct answer is to refer her for prenatal care. Prenatal care is essential to monitor the health of both the mother and the fetus during pregnancy. While notifying her parents may be important for support and involvement, the priority is ensuring the adolescent receives medical care. Teaching breastfeeding methods and offering nutritional instructions are important but are not the immediate priority in this situation where prenatal care is urgently needed.

5. During a home visit, the nurse observes that a client with limited mobility has difficulty preparing meals. What should the nurse do first?

• A. suggest that the client use a meal delivery service
• B. assist the client in meal planning
• C. refer the client to a dietitian
• D. educate the client on easy-to-prepare healthy meals

Correct answer: B

Rationale: Assisting the client in meal planning is the most appropriate initial action as it addresses the immediate issue of meal preparation. By helping the client plan meals according to their dietary needs and limitations, the nurse can support the client in maintaining a healthy diet despite limited mobility. While suggesting a meal delivery service (Choice A) may be a viable option, assisting in meal planning allows for more personalized and sustainable solutions. Referring the client to a dietitian (Choice C) may be necessary for specialized nutritional advice but is not the first step in addressing the immediate concern. Educating the client on easy-to-prepare healthy meals (Choice D) could be beneficial, but meal planning is a more comprehensive approach to ensure the client's dietary needs are met consistently.

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