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During a two-week postoperative follow-up home visit, a client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and feelings of malaise. The client's vital signs are an oral temperature of 101.80F (38.8° C), a blood pressure of 100/50 mm Hg, a heart rate of 104 beats/minute, and a respiratory rate of 18 breaths/minute. What is the appropriate action for the nurse to take?
- A. Recheck the client's vital signs in 30 minutes.
- B. Have the client transported via ambulance to the hospital.
- C. Determine the client's current oxygen saturation rate.
- D. Instruct the client to drive to the hospital for admission.
Correct Answer: B
Rationale: Having the client transported via ambulance to the hospital is the most appropriate action. The client's symptoms suggest possible complications that require immediate medical attention. Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection.
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A mother who is six weeks postpartum reports to the home health nurse that her milk supply seems to be diminishing. The nurse notices that the mother's 16-month-old child is constantly vying for her attention. What is the best advice the nurse can provide to help the mother with breastfeeding while also caring for a toddler?
- A. Have the 16-month-old child play in another room during breastfeeding.
- B. Read a book to the 16-month-old child while the mother is breastfeeding the infant.
- C. Encourage the toddler to watch TV while the mother is breastfeeding the baby.
- D. Give the toddler crayons and paper while the mother is breastfeeding the infant.
Correct Answer: B
Rationale: Reading a book to the 16-month-old child while the mother is breastfeeding the infant can be a practical solution. It allows the mother to attend to both children simultaneously, keeping the older child engaged while tending to the infant.
A teenager with a history of recurring atopic dermatitis (eczema) tells the school nurse of a desire to play high school sports. Which action should the nurse take?
- A. Advise the teenager to shower with non-perfumed soaps immediately after practice.
- B. Inform the parents of problems associated with perspiration for those with eczema.
- C. Inform the athletic coach of the teenager's skin condition and its manifestations.
- D. Encourage the teenager to join the swim team instead of an outdoor sport.
Correct Answer: A
Rationale: Showering with non-perfumed soaps immediately after practice is a good practice for a teenager with a history of recurring atopic dermatitis (eczema) who wants to play high school sports. Heat and humidity can cause perspiration, which intensifies itching with atopic dermatitis (eczema), so the client should be encouraged to shower, using non-perfumed soaps, as soon as possible after physical activity to remove perspiration.
The school nurse is reviewing adolescent students' incident reports. Which observation would best indicate that the objectives of Healthy People 2030 are being met?
- A. The number of requests for pregnancy tests has increased compared to the previous year.
- B. Fewer firearms were found on school premises this year compared to last year.
- C. There has been a decrease in the number of students enrolled in the school this year.
- D. The rate of absenteeism has significantly risen over the past two years.
Correct Answer: B
Rationale: A decrease in the number of firearms found on school premises could suggest improvements in school safety, one of the focus areas of Healthy People 2030.
The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2030 objectives are being addressed?
- A. The number of requests for pregnancy testing is higher than last year.
- B. Decrease in the number of sick days.
- C. Increase in the number of students participating in physical education.
- D. Improvement in the overall health of the student population.
Correct Answer: D
Rationale: An improvement in the overall health of the student population is the best indication that the Healthy People 2030 objectives are being addressed. The Healthy People 2030 objectives aim to improve health and well-being nationwide. Therefore, an improvement in the overall health of the student population suggests that these objectives are being met.
A nurse is preparing a nutrition class for a group of senior citizens at a local community center. The focus of the class is to highlight the quantity and types of fats in various foods. What is the most effective teaching method the nurse should employ?
- A. Exhibit posters showcasing different foods and discuss their fat content.
- B. Identify the most commonly consumed foods among the group and discuss each product's nutritional information.
- C. Screen a film about preparing tasty meals with low-fat ingredients.
- D. Request each senior to bring a food item for others to sample, then estimate the fat content of these foods.
Correct Answer: B
Rationale: Identifying the most commonly consumed foods among the group and discussing each product's nutritional information would be the most effective method. This approach is personalized and relevant, making the information more likely to be remembered and applied.