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The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
- A. Administer the dose as prescribed.
- B. Hold the medication.
- C. Call the healthcare provider.
- D. Repeat the vital signs in 30 minutes.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The wife of an older adult man who has had diabetes mellitus for the past 10 years reports to the home health nurse that her husband fell yesterday while taking his daily walk in the neighborhood. He has a bruised hand and a small abrasion on his left knee. The nurse assesses that his neurologic vital signs are stable. To reduce risk for future falls, which assessment is most important for the nurse to obtain?
- A. current blood sugar level
- B. degree of paresthesia in feet
- C. wound healing of knee abrasion
- D. A1c glycosylated hemoglobin
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is planning a community event to raise awareness about mental health. Which activity should be included to best engage participants?
- A. lectures by mental health professionals
- B. interactive workshops on stress management
- C. distribution of mental health resources
- D. screenings for depression and anxiety
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?
- A. Blood pressure of 180/100 mm Hg.
- B. Urine output of 50 mL in 4 hours.
- C. Heart rate of 100 beats per minute.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Urine output of 50 mL in 4 hours indicates oliguria, which can be a sign of worsening renal function and requires immediate intervention. In acute renal failure, maintaining adequate urine output is crucial to prevent further kidney damage and manage fluid balance. A high blood pressure reading (Option A) is concerning but may not require immediate intervention in this scenario as it could be due to the history of hypertension. A heart rate of 100 beats per minute (Option C) is slightly elevated but may not be the most critical finding at this moment. Nausea and vomiting (Option D) are important to assess but are not as urgent as addressing oliguria in a client with acute renal failure.
A public health nurse is planning a smoking cessation program for a local community. Which component is most important to include in the program?
- A. information on the health risks of smoking
- B. strategies for coping with withdrawal symptoms
- C. testimonials from former smokers
- D. distribution of nicotine replacement therapy
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?
- A. Call the pharmacy to determine what medications she is taking
- B. Seek the family's assistance in taking care of the client
- C. Complete a physical and mental exam on the client
- D. Call the adult protective services to obtain emergency nursing home placement
Correct Answer: C
Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.