Nokea
A community health nurse is developing a plan to improve the community's environmental health. Which of the following actions should the nurse take first?
- A. Encourage community involvement in environmental improvement.
- B. Establish a timeframe for environmental improvements.
- C. Request funding from community organizations.
- D. Collect information about the community's environmental status.
Correct Answer: D
Rationale: The correct answer is D - Collect information about the community's environmental status. This is the first step because it allows the nurse to assess the current environmental health issues in the community. By gathering data, the nurse can identify specific problems and prioritize interventions based on evidence. This information will guide the development of an effective plan tailored to address the community's specific needs.
Choice A is incorrect because community involvement should come after assessing the environmental status. Choice B is incorrect as setting a timeframe is premature without understanding the extent of the issues. Choice C is incorrect as funding should be sought once the plan is developed.
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A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly-licensed nurse requires intervention by the staff nurse?
- A. Waits for 2 minutes between suctions
- B. Engaging in policy development and encourage and assist persons to communicate their needs
- C. Giving a very informative and engaging presentation
- D. Identifying and planning for high-risk populations
Correct Answer: A
Rationale: The correct answer is A because waiting for 2 minutes between suctions is not recommended practice for tracheostomy care. Suctioning should be performed as needed based on the patient's clinical presentation, not on a fixed time interval. Waiting too long between suctions can lead to ineffective removal of secretions, compromising the patient's airway.
Choice B, C, and D are incorrect because they are unrelated to the scenario of suctioning a tracheostomy. Choice B refers to policy development and communication skills, Choice C mentions giving a presentation, and Choice D involves planning for high-risk populations. These choices do not pertain to the immediate nursing intervention needed during tracheostomy care.
A nurse in a urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
- A. Olguria
- B. Decreased sensitivity
- C. Evaluate the number of clients presenting with similar diseases
- D. Introduction of a heart-healthy curriculum beginning in the first grade
Correct Answer: A
Rationale: The correct answer is A: Oliguria. When an infant presents with vomiting, diarrhea, and decreased oral intake, they are at risk of dehydration. Oliguria, which is decreased urine output, is a common manifestation of dehydration. This occurs as the body tries to conserve fluid. Other choices are incorrect as they are not related to the symptoms described. Decreased sensitivity, evaluate the number of clients presenting with similar diseases, and introduction of a heart-healthy curriculum are all unrelated to the clinical presentation of vomiting, diarrhea, and decreased oral intake in an infant.
A school nurse is developing a primary prevention strategy for school-aged children. Which of the following interventions would the nurse most likely implement?
- A. Developing individualized exercise programs for overweight children
- B. Drafting policy for increases in noncompetitive physical activity programs
- C. Monitoring body mass index (BMI) in children to identify elevations before they become difficult to manage
- D. Notifying parents and/or guardians of their child's height–weight scale in comparison with national norms
Correct Answer: B
Rationale: The correct answer is B because drafting policies for increases in noncompetitive physical activity programs aligns with primary prevention strategies. This intervention focuses on promoting overall health and preventing health problems before they occur. This approach targets the entire school population rather than individual children, making it a more effective primary prevention strategy.
Choice A is incorrect as it focuses on individualized interventions rather than population-based prevention. Choice C focuses on early detection rather than prevention. Choice D, while involving parents, does not address primary prevention but rather provides information after the fact.
A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life sustaining measures. Which of the following actions should the nurse take?
- A. Arrange for an ethics committee meeting
- B. Balancing the bottle on the sterile basin while pouring the liquid
- C. Determine the client's current anxiety level
- D. Tell the child there will be discomfort during the catheter insertion
Correct Answer: A
Rationale: The correct answer is A: Arrange for an ethics committee meeting. In this scenario, the client has clear advance directives that they do not want life-sustaining measures. The nurse's primary responsibility is to advocate for the client's wishes, as outlined in their advance directives. By arranging an ethics committee meeting, the nurse can facilitate a discussion involving healthcare professionals, the client's family, and possibly legal experts to ensure that the client's wishes are respected while also addressing the concerns of the family. This process allows for a thorough review of the situation and consideration of all perspectives before making a final decision.
Choice B is incorrect because it is unrelated to the client's care preferences. Choice C is irrelevant as the client's anxiety level does not impact the decision about life-sustaining measures. Choice D is also unrelated to the client's advance directives and is not a priority in this situation.
A nurse is caring for an older client who is struggling to manage her type 2 diabetes mellitus. The nurse should recognize which social determinants of this client's health? (Select all that apply.)
- A. Household income of $23,000 per year
- B. Reading level of a third grader
- C. Medication ineffective due to error in prescription
- D. Originally from Sudan
Correct Answer: A
Rationale: The correct answer is A: Household income of $23,000 per year. This is a social determinant of health because low income can impact access to healthy foods, medications, and healthcare services, affecting diabetes management. Choice B, reading level, is related to health literacy but not specifically a social determinant in this scenario. Choice C, medication error, is a healthcare system issue. Choice D, origin from Sudan, is related to cultural background but not directly a social determinant affecting diabetes management.