Nokea
The nurse is developing a community health program to address the high rates of hypertension in a neighborhood. Which intervention should the nurse prioritize?
- A. conducting free blood pressure screenings
- B. distributing educational materials on hypertension
- C. holding workshops on stress management
- D. partnering with local gyms to offer discounted memberships
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?
- A. Administer a prescribed bronchodilator
- B. Increase the oxygen flow rate
- C. Instruct the client to perform pursed-lip breathing
- D. Notify the healthcare provider immediately
Correct Answer: C
Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?
- A. Hold the medication.
- B. Call the healthcare provider.
- C. Administer the medication.
- D. Check the blood pressure.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is developing a workshop on cancer prevention for a group of adults at a wellness bar. Which recommendation should the nurse include in the workshop?
- A. know the 4 warning signs of cancer
- B. maintain a healthy weight and exercise regularly
- C. refrain from alcohol
- D. obtain at least 6 to 10 hours of sleep per night
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is caring for a client with a chest tube. Which intervention is most important to include in the plan of care?
- A. Maintain continuous suction on the chest tube.
- B. Clamp the chest tube during client movement.
- C. Ensure that the chest tube is clamped for at least 8 hours each day.
- D. Keep the collection chamber below the level of the chest.
Correct Answer: D
Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.
A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?
- A. Continue the heparin infusion as prescribed.
- B. Decrease the heparin infusion rate.
- C. Increase the heparin infusion rate.
- D. Stop the heparin infusion and notify the healthcare provider.
Correct Answer: D
Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.