Nokea
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.
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The healthcare provider is planning a health education session for new parents on infant care. Which topic should be prioritized?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Recognizing signs of infant dehydration is crucial for ensuring the health and well-being of infants. Dehydration can be life-threatening for infants if not addressed promptly. Proper diaper changing techniques, while important for hygiene, can be learned incrementally. The immunization schedule and breastfeeding positions are also essential topics, but identifying signs of dehydration takes precedence as it requires immediate attention to prevent serious complications.
On a day when the temperature is expected to drop below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces available in a shelter. It is most important for which person to be admitted at night?
- A. an adult who was hit by a car 3 weeks ago
- B. a young person with diabetes mellitus
- C. a middle-aged person who has hypertension
- D. an older person who is malnourished
Correct Answer: D
Rationale: Malnourished individuals are at higher risk of severe complications from cold exposure due to their weakened immune system and decreased ability to regulate body temperature. This places them at a greater risk of hypothermia and other cold-related conditions, making them the most vulnerable group in need of shelter. Choice A is not the most critical as the injury is from 3 weeks ago and should have received appropriate medical care by now. Choice B, a young person with diabetes mellitus, while vulnerable, can manage their condition with proper medication and care. Choice C, a middle-aged person with hypertension, may need monitoring but is less susceptible to immediate harm from cold exposure compared to a malnourished individual.
To prepare a presentation on the greatest health concern facing the city, how should the health nurse begin collecting data?
- A. Review morbidity data for the city's population compiled by the Bureau of Vital Statistics
- B. Conduct a random telephone survey to determine the public's perception about health problems
- C. Survey major hospitals in the area to determine the most common reasons for admissions
- D. Call American Medical Association members to determine the most frequently treated diagnoses
Correct Answer: A
Rationale: The correct answer is to review morbidity data for the city's population compiled by the Bureau of Vital Statistics. Morbidity data provides detailed and accurate information on the health issues prevalent in the city's population. This data is essential as it reflects actual health conditions rather than perceptions or specific hospital data. Conducting a telephone survey (choice B) may provide subjective opinions rather than objective data. Surveying hospitals (choice C) may only capture data on hospitalized cases and may not represent the entire population. Contacting American Medical Association members (choice D) may provide insights into medical treatments but may not reflect the overall health concerns of the city's population.
The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?
- A. Jaundice.
- B. Ascites.
- C. Peripheral edema.
- D. Spider angiomas.
Correct Answer: D
Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.
The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?
- A. client's score on an alcohol screening instrument
- B. results of a urine drug and alcohol screen
- C. most recent community census data
- D. documentation of client education in the nursing record
Correct Answer: D
Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.