Nursing Elites

1. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?

• A. Participants can identify at least three coping strategies to use during labor.
• B. Participants can list signs of labor and when to come to the hospital.
• C. Participants can describe three pain relief measures to use during labor.
• D. Participants can perform three relaxation techniques to use during labor.

Correct answer: A

Rationale: The priority expected outcome for childbirth preparation classes is for participants to be able to identify coping strategies to use during labor. This is crucial as coping strategies can help women manage pain, stress, and anxiety during childbirth. Choice B is important but does not focus on coping strategies needed during labor. Choice C is relevant but focuses solely on pain relief measures which are a part of coping strategies. Choice D is also relevant but does not encompass all aspects of coping with labor effectively.

2. The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2020 objectives are being addressed?

• A. the absenteeism rate has increased greatly over the past two years
• B. during the last year fewer firearms were retrieved on school property
• C. the number of requests for pregnancy testing is higher than last year
• D. decline in the number of students enrolled in school during the year

Correct answer: B

Rationale: The correct answer is B. A decrease in firearms retrieved on school property is a positive indication that the Healthy People 2020 objectives are being addressed. This finding suggests progress in reducing violence and improving safety in schools, which aligns with the goals of promoting overall health and safety among adolescents. Choices A, C, and D do not directly relate to the Healthy People 2020 objectives. Increased absenteeism, higher requests for pregnancy testing, and a decline in student enrollment do not necessarily reflect the specific health and safety goals outlined in Healthy People 2020.

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

• A. Weight gain of 1 pound.
• B. Dizziness.
• C. Fatigue.
• D. Muscle cramps.

Correct answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.

4. During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?

• A. Administer a prescribed bronchodilator
• B. Increase the oxygen flow rate
• C. Instruct the client to perform pursed-lip breathing
• D. Notify the healthcare provider immediately

Correct answer: C

Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.

5. The nurse is documenting the medical history of a young adult who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes a day, and his father died of a heart attack at the age of 45. Which annual screening is most important for the nurse to include?

• A. peripheral neuropathy
• B. renal insufficiency
• C. retinopathy
• D. hyperlipidemia

Correct answer: D

Rationale: The most important annual screening for the nurse to include is hyperlipidemia. Given the client's smoking history, family history of premature heart disease, and the increased risk of cardiovascular complications associated with diabetes, screening for hyperlipidemia is crucial. This screening is essential in assessing the client's risk of developing cardiovascular disease, which is a significant concern in this case. Peripheral neuropathy (choice A) is a common long-term complication of diabetes but may not be the most immediate concern in this scenario. Renal insufficiency (choice B) is also a complication of diabetes, but given the client's high cardiovascular risk, hyperlipidemia screening takes priority. Retinopathy (choice C) is an important complication of diabetes affecting the eyes, but in this case, focusing on cardiovascular risk assessment through hyperlipidemia screening is more critical.

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