Nursing Elites

1. The nurse is caring for a client with hyperthyroidism. Which assessment finding requires immediate intervention?

• A. Heart rate of 100 beats per minute.
• B. Blood pressure of 150/90 mm Hg.
• C. Respiratory rate of 24 breaths per minute.
• D. Weight loss of 5 pounds in one week.

Correct answer: D

Rationale: Weight loss of 5 pounds in one week in a client with hyperthyroidism is concerning as it may indicate severe hypermetabolism, leading to potential complications such as cardiac arrhythmias, muscle weakness, and other metabolic disturbances. Rapid weight loss in hyperthyroidism indicates an accelerated metabolic rate and increased energy expenditure, which can be detrimental to the client's health. The other assessment findings (heart rate of 100 beats per minute, blood pressure of 150/90 mm Hg, respiratory rate of 24 breaths per minute) are commonly seen in clients with hyperthyroidism and may not necessarily require immediate intervention unless they are significantly outside the normal range or causing distress to the client.

2. A client with a history of alcoholism is admitted with pancreatitis. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Nausea and vomiting.
• B. Epigastric pain radiating to the back.
• C. Temperature of 102°F (38.9°C).
• D. Mild jaundice.

Correct answer: C

Rationale: A temperature of 102°F (38.9°C) is the most important assessment finding to report to the healthcare provider in a client with pancreatitis and a history of alcoholism. Fever in this context can indicate infection, which is a serious complication requiring immediate intervention. Nausea and vomiting (choice A) are common symptoms of pancreatitis but may not require immediate intervention unless severe. Epigastric pain radiating to the back (choice B) is a classic symptom of pancreatitis and should be addressed, but a fever takes precedence. Mild jaundice (choice D) may be present in pancreatitis but is not as urgent as a high temperature signaling possible infection.

3. Prior to implementing a community health program targeting teenage smoking, which information is most important for the nurse to obtain?

• A. greater access to any healthcare provider
• B. allowance for early discharge
• C. Prevalence and patterns of smoking among teenagers
• D. approval by the network healthcare provider

Correct answer: C

Rationale: The most important information for the nurse to obtain before implementing a community health program targeting teenage smoking is the prevalence and patterns of smoking among teenagers. Understanding this data is crucial to tailor the program to the specific needs and behaviors of the target group, ensuring it addresses the root causes effectively. Choices A, B, and D are unrelated to the specific needs of the target group and do not provide essential information for designing an effective smoking cessation program for teenagers.

4. A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

• A. Continue the heparin infusion as prescribed.
• B. Decrease the heparin infusion rate.
• C. Increase the heparin infusion rate.
• D. Stop the heparin infusion and notify the healthcare provider.

Correct answer: D

Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.

5. A client with a history of heart failure is admitted with severe dyspnea. Which intervention should the nurse implement first?

• A. Administer oxygen at 2 liters per minute via nasal cannula.
• B. Place the client in a high Fowler's position.
• C. Obtain a 12-lead electrocardiogram (ECG).
• D. Administer intravenous furosemide (Lasix).

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position first. This intervention helps improve breathing and oxygenation in clients with severe dyspnea, including those with heart failure. Elevating the head of the bed reduces the work of breathing and enhances lung expansion. Administering oxygen, obtaining an ECG, and administering furosemide are important interventions in the management of heart failure, but placing the client in a high Fowler's position is the priority to address the immediate need for improved breathing and oxygenation.

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