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The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?
- A. Temperature of 99‚°F (37.2‚°C).
- B. Respiratory rate of 20 breaths per minute.
- C. Heart rate of 90 beats per minute.
- D. Fatigue.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?
- A. Blood glucose of 250 mg/dL.
- B. Serum potassium of 3.5 mEq/L.
- C. Serum sodium of 135 mEq/L.
- D. Arterial blood pH of 7.30.
Correct Answer: D
Rationale: Corrected Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.
A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?
- A. Increased respiratory rate.
- B. Absence of breath sounds.
- C. Expiratory wheezes.
- D. Productive cough with green sputum.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A community health nurse is helping a group of nursing students plan a tertiary prevention program for a local community clinic that serves a majority Hispanic population. Which service project meets the requirement of a tertiary prevention program and would best serve this population?
- A. teach clients about recommended immunizations for children
- B. demonstrate foot care to a group of clients who have diabetes
- C. take blood pressures at a local shopping mall in the community
- D. instruct teens about prevention of sexually transmitted diseases
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important for the community?
- A. family planning center
- B. accessibility to trauma care
- C. annual health fair
- D. weather-related disaster plan
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.