Nokea
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?
- A. An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
- B. An adolescent admitted the prior night with Tylenol intoxication
- C. A middle-aged client with an internal automatic defibrillator and complaints of 'passing out at unknown times' admitted yesterday
- D. A school-age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts
Correct Answer: A
Rationale: The correct answer is A because a client with diabetic ketoacidosis (DKA) that is being well-managed and has shown improvement within 24 hours is more stable and can be considered for discharge sooner than those with more acute or unstable conditions. Choice B is incorrect as Tylenol intoxication may require further monitoring and intervention. Choice C is incorrect as a client with an automatic defibrillator and episodes of passing out needs careful evaluation and monitoring. Choice D is incorrect as suspected bacterial meningitis is a serious condition that typically requires a longer hospital stay for treatment and observation.
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A pre-term baby develops nasal flaring, cyanosis, and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?
- A. Cardiopulmonary resuscitation
- B. Insertion of a chest tube
- C. Oxygen therapy
- D. Assisted ventilation
Correct Answer: B
Rationale: The correct answer is B: Insertion of a chest tube. In a case of spontaneous pneumothorax, the primary intervention is to insert a chest tube. This procedure allows the trapped air to escape from the pleural space, relieving pressure and enabling the lung to re-expand. Choices A, C, and D are not the initial interventions for spontaneous pneumothorax. Cardiopulmonary resuscitation is indicated for cardiac arrest, oxygen therapy may provide supportive care but does not address the underlying issue of trapped air in the pleural space, and assisted ventilation may be needed later but is not the first-line treatment for a pneumothorax.
What is the main objective of the Expanded Program on Immunization (EPI)?
- A. Provide healthcare to all individuals
- B. Reduce child mortality
- C. Eliminate vaccine-preventable diseases
- D. Promote healthy lifestyles
Correct Answer: C
Rationale: The main objective of the Expanded Program on Immunization (EPI) is to eliminate vaccine-preventable diseases. While providing healthcare to all individuals and reducing child mortality are important goals, the primary focus of EPI is specifically on preventing diseases through immunization. Promoting healthy lifestyles, although beneficial, is not the primary aim of the EPI.
A nurse organizes a community action group to help resolve health problems in a low-income neighborhood with a large population of recent immigrants from Africa. What problem should the nurse address first?
- A. High rate of unemployment.
- B. Low immunization rate of children.
- C. Provision of substandard health care.
- D. Access to bilingual care providers.
Correct Answer: B
Rationale: The correct answer is B: Low immunization rate of children. Addressing low immunization rates is crucial as it directly impacts the health of children and the community by preventing the spread of infectious diseases. Option A, high rate of unemployment, though important for overall well-being, is not the most immediate health concern. Option C, provision of substandard health care, is a significant issue but may not be as urgent as ensuring children are immunized. Option D, access to bilingual care providers, is important for effective communication but is not as critical as addressing low immunization rates in this scenario.
The major target of the Philippine Family Program are women belonging to the high-risk group which includes:
- A. Women under 20 or over 35 years old
- B. Women suffering from certain medical conditions that contradict pregnancy
- C. All these groups
- D. Women who have had at least 4 deliveries
Correct Answer: C
Rationale: The correct answer is C, 'All these groups.' The Philippine Family Program targets women under 20 years old, over 35 years old, those with certain medical conditions that contradict pregnancy, and women who have had at least 4 deliveries. Therefore, choice C is the correct answer because it encompasses all the high-risk groups identified by the program. Choices A, B, and D are incorrect because they do not cover all the specified high-risk groups targeted by the program.
Which topic should be included in planning a secondary prevention project for the local retirement community?
- A. Safety measures in the home.
- B. Adult immunization program.
- C. Rehabilitation after surgery.
- D. Vision and hearing screening.
Correct Answer: D
Rationale: In planning a secondary prevention project for the local retirement community, vision and hearing screening should be included. This is crucial as sensory impairments are common among older adults and early detection through screening can help in preventing further complications. Safety measures in the home, adult immunization programs, and rehabilitation after surgery are important but fall more under primary or tertiary prevention strategies rather than secondary prevention, which focuses on early detection and intervention to prevent the progression of health conditions.