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Which client has the highest risk for devel oping community-acquired pneumonia?
- A. a 40-year ol d fi rst-grade teacher w ho works w ith underprivileged children
- B. a 75-year ol d reti red secretary w ith exercise-induced w heezing
- C. a 60-year ol d homeless person who i s an alcoholic and smokes
- D. a 35-year old aerobics instructor who skips meals and eats only vegetables -
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with type 2 diabetes mellitus is admitted with hyperosmolar hyperglycemic state (HHS). Which laboratory result requires immediate intervention?
- A. Serum osmolality of 320 mOsm/kg.
- B. Serum glucose of 600 mg/dL.
- C. Serum potassium of 4.5 mEq/L.
- D. Serum sodium of 140 mEq/L.
Correct Answer: B
Rationale: A serum glucose level of 600 mg/dL is extremely high in a client with hyperosmolar hyperglycemic state (HHS) and poses a significant risk of serious complications such as dehydration, coma, and electrolyte imbalances. Rapid intervention is crucial to normalize the glucose level and prevent further deterioration. Serum osmolality of 320 mOsm/kg, serum potassium of 4.5 mEq/L, and serum sodium of 140 mEq/L, while important to monitor in HHS, do not represent an immediate life-threatening condition that requires urgent intervention compared to the critically high glucose level.
A public health nurse is developing a campaign to promote breast cancer screening. Which population should be the primary target of this campaign?
- A. women aged 20-30
- B. women aged 30-40
- C. women aged 40-50
- D. women aged 50-60
Correct Answer: C
Rationale: The correct answer is women aged 40-50. This age group is at an increased risk for breast cancer and should be the primary target for screening campaigns. Women in this age range are more likely to benefit from regular screening as early detection can lead to better outcomes. Choices A, B, and D are incorrect because women aged 20-30 are generally not recommended for routine screening due to their lower risk, women aged 30-40 have a moderate risk but are not the primary target group, and women aged 50-60 should still be screened but targeting the 40-50 age group is more crucial for early detection and intervention.
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 school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?
- A. hepatitis B
- B. tetanus, diphtheria, and pertussis (Tdap)
- C. varicella
- D. measles, mumps, and rubella (MMR)
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct Answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.