Nursing Elites

1. The nurse is planning a health education program for 10-year-olds. Which setting is most likely to increase the preadolescents' participation in the program?

• A. the school classroom
• B. community center
• C. home of one of the children
• D. a local place of worship

Correct answer: A

Rationale: The school classroom is the most suitable setting to increase preadolescents' participation in a health education program. At the age of 10, children are accustomed to the school environment, making it familiar and comfortable for them. This familiarity can help reduce anxiety and increase engagement during the program. Community centers may be less familiar and could pose distractions, potentially reducing participation. Conducting the program at the home of one of the children may lead to unequal access for other participants and may not provide the necessary facilities for an educational session. A local place of worship may not be perceived as a neutral or suitable environment for a health education program, potentially hindering participation.

2. A school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?

• A. hepatitis B
• B. tetanus, diphtheria, and pertussis (Tdap)
• C. varicella
• D. measles, mumps, and rubella (MMR)

Correct answer: B

Rationale: The most important vaccine for the school nurse to include in the vaccination clinic for middle school students is the tetanus, diphtheria, and pertussis (Tdap) vaccine. Tdap is recommended for preteens as part of the routine vaccination schedule to protect against these serious diseases. Hepatitis B, varicella, and MMR vaccines are also important but for this specific age group, Tdap takes precedence to ensure protection against tetanus, diphtheria, and pertussis.

3. During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?

• A. Instruct the client to monitor her blood pressure at home
• B. Refer the client to her healthcare provider for further evaluation
• C. Educate the client on lifestyle changes to reduce blood pressure
• D. Recheck the blood pressure in 15 minutes

Correct answer: B

Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.

4. The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?

• A. Blood glucose level of 150 mg/dL.
• B. Weight gain of 2 pounds in 24 hours.
• C. Decreased urine output.
• D. Temperature of 100.3°F (37.9°C).

Correct answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

5. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?

• A. request transport of the child to his pediatrician's office
• B. call the child's parents and send him home for the day
• C. compare the child's body mass index to normal values
• D. measure the child's pulse and blood pressure every 15 minutes

Correct answer: D

Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.

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