which of the following patients would the home care nurse assess first
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Nursing Elites

HESI LPN

Community Health HESI Study Guide

1. Which of the following patients should the home care nurse assess first?

Correct answer: A

Rationale: The correct answer is A. A patient with known COPD and difficulty breathing after physical exertion like climbing stairs requires immediate assessment by the nurse. This could indicate a potential exacerbation of COPD, which needs prompt intervention to prevent respiratory distress. Choices B, C, and D describe important patient situations that also require attention, but the urgency is higher with a COPD patient experiencing difficulty breathing.

2. The occupational health nurse is completing a yearly self-evaluation. Which activity should the nurse document as an example of proficient performance criteria in professionalism?

Correct answer: B

Rationale: Maintaining chairmanship of the hospital nursing council demonstrates leadership and professionalism. This role involves overseeing and leading nursing activities at the hospital, showcasing a high level of responsibility and professionalism. Choices A, C, and D do not directly relate to demonstrating professionalism. Contributing money to a professional society, documenting the nursing process, or developing policy initiatives, while valuable activities, do not directly reflect the same level of leadership and professionalism as maintaining chairmanship.

3. In providing comprehensive family health care, the nurse utilizes four (4) basic processes. These are listed in the order in which they are carried out as follows:

Correct answer: A

Rationale: The correct order for the basic processes in providing comprehensive family health care is assessment, planning, intervention, and evaluation. Assessment is the first step to gather information, followed by planning to set goals and strategies, then intervention to implement the plan, and finally evaluation to assess the outcomes. Choice A is correct as it follows this logical sequence. Choices B, C, and D are incorrect because they do not follow the correct order of these essential processes in nursing care.

4. A client with a urinary tract infection is receiving ciprofloxacin (Cipro). The nurse should monitor the client for which of the following side effects?

Correct answer: D

Rationale: Ciprofloxacin can cause tendonitis and an increased risk of tendon rupture. Monitoring for tendonitis is crucial as it can lead to significant musculoskeletal issues. Choices A, B, and C are incorrect as hypertension, hypoglycemia, and hyperkalemia are not typically associated with ciprofloxacin use.

5. A client is admitted for COPD. Which finding would require the nurse's immediate attention?

Correct answer: B

Rationale: Restlessness and confusion are signs of hypoxia and hypercapnia in a client with COPD, indicating that the client's condition may be deteriorating rapidly. Immediate attention is necessary to prevent further complications. Nausea and vomiting (Choice A) may be related to various factors but do not directly indicate respiratory distress. Low-grade fever and cough (Choice C) are common in COPD and may not require immediate intervention. Irritating cough and liquefied sputum (Choice D) are typical symptoms of COPD exacerbation but do not signal an immediate need for attention as restlessness and confusion.

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