Nursing Elites

1. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?

• A. Oxygen saturation of 88%.
• B. Use of accessory muscles for breathing.
• C. Respiratory rate of 26 breaths per minute.
• D. Barrel-shaped chest.

Correct answer: C

Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.

2. During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?

• A. Call the pharmacy to determine what medications she is taking
• B. Seek the family's assistance in taking care of the client
• C. Complete a physical and mental exam on the client
• D. Call the adult protective services to obtain emergency nursing home placement

Correct answer: C

Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.

3. The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?

• A. client's score on an alcohol screening instrument
• B. results of a urine drug and alcohol screen
• C. most recent community census data
• D. documentation of client education in the nursing record

Correct answer: D

Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.

4. A community health nurse is addressing the issue of substance abuse in the community. Which intervention should be prioritized?

• A. Providing education on the dangers of substance abuse
• B. Setting up a support group for individuals struggling with addiction
• C. Partnering with local law enforcement to reduce drug availability
• D. Creating a confidential hotline for reporting substance abuse

Correct answer: D

Rationale: Creating a confidential hotline for reporting substance abuse should be prioritized because it offers a safe and accessible way for individuals to seek help and support for their substance abuse issues. This intervention allows individuals to report their concerns anonymously and seek guidance without fear of judgment or repercussions. Providing education on the dangers of substance abuse (Choice A) is important but may not be as immediately impactful as offering a direct avenue for help. Setting up a support group (Choice B) is valuable but may not reach as many individuals or provide the same level of anonymity as a confidential hotline. Partnering with law enforcement (Choice C) is crucial for addressing substance abuse issues from a legal perspective but may not directly address the immediate needs of individuals seeking help.

5. A client with a history of peptic ulcer disease is admitted with sudden severe abdominal pain. Which finding indicates the possibility of a perforated ulcer?

• A. Bowel sounds are hyperactive in all quadrants.
• B. Abdomen is soft and nondistended.
• C. The client reports sudden severe abdominal pain.
• D. Blood pressure of 110/70 mm Hg.

Correct answer: C

Rationale: The correct answer is C. Sudden severe abdominal pain is a key clinical manifestation of a perforated ulcer. The sudden onset of severe pain is concerning for a perforation in the ulcer, which can lead to peritonitis if not promptly addressed. Choices A, B, and D are incorrect because hyperactive bowel sounds, a soft and nondistended abdomen, and a blood pressure of 110/70 mm Hg are not specific indicators of a perforated ulcer. Hyperactive bowel sounds may suggest increased gastrointestinal motility, a soft abdomen may not necessarily indicate a perforation, and a blood pressure of 110/70 mm Hg is within normal limits and does not directly relate to a perforated ulcer.

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