A home health nurse is reviewing the laboratory results for several clients with heart failure. Which client finding would the nurse report to the health care provider immediately?

Correct Answer: C

Rationale: In this scenario, the correct answer is option C - B-type natriuretic peptide (BNP) level of 550 pg/ml. This finding would need to be reported to the health care provider immediately because an elevated BNP level in a client with heart failure indicates worsening heart failure and the need for prompt intervention or adjustment of treatment. Monitoring BNP levels is crucial in managing heart failure patients as it helps in assessing the severity of heart failure and guiding treatment decisions. Option A, total cholesterol of 190, is not an immediate concern in a client with heart failure. Option B, glycosylated hemoglobin of 7%, is indicative of good diabetes control but is not the most critical finding to report in a client with heart failure. Option D, potassium level of 3.7, is within the normal range and does not require immediate reporting unless there are specific concerns related to the client's condition and medications. In the context of community health nursing, understanding the significance of laboratory results in managing chronic conditions like heart failure is vital. Nurses play a crucial role in monitoring these results, recognizing abnormalities, and collaborating with the healthcare team to ensure timely interventions to optimize patient outcomes. This question highlights the importance of clinical judgment and prioritization in providing safe and effective care to clients in the community setting.

Correct Answer: A

Rationale: In this scenario, the correct action for the RN to take is option A: have the client transported via ambulance to the hospital. This choice is based on the client's presentation of symptoms indicating a potential serious postoperative complication, such as an anastomotic leak after gastric bypass surgery. The presence of tenderness, shoulder pain, malaise, and elevated temperature along with hypotension, tachycardia, and tachypnea are concerning signs that warrant immediate medical attention. Option B, to recheck vital signs in 30 minutes, is not appropriate in this case as the client's symptoms suggest a potentially critical condition that requires prompt intervention. Option C, instructing the client to drive to the hospital, is unsafe due to the client's condition and the need for urgent medical evaluation. Option D, determining the client's current symptoms, is unnecessary as the client's presentation already indicates the need for immediate medical assessment and intervention. In an educational context, this scenario highlights the importance of recognizing and responding to postoperative complications promptly in community health nursing. It emphasizes the critical thinking skills needed to prioritize actions based on assessment findings and the significance of timely intervention in ensuring patient safety and optimal outcomes. Nurses must be prepared to act decisively in emergent situations to provide appropriate care and support to patients in the community setting.

Correct Answer: B

Rationale: In this scenario, the most appropriate initial action for the nurse to take is to review the client's current medication regimen (Option B). This is the correct choice because before addressing the issue of expired medications, the nurse must first assess the client's current medication usage to ensure they are receiving the necessary treatment for their health conditions. Option A, instructing the client to dispose of the expired medications, is not the best first step because it does not address the immediate concern of ensuring the client's current health needs are being met. Additionally, there may be specific disposal protocols that need to be followed for medications. Option C, contacting the client's healthcare provider, while important, should come after assessing the client's current medication regimen. The nurse needs to have a clear understanding of the client's medication history and needs before involving the healthcare provider. Option D, educating the client on the dangers of taking expired medications, is not the priority at this moment. While education is crucial, the immediate focus should be on ensuring the client's current medication regimen is appropriate and addressing any potential gaps in their care. In an educational context, this question highlights the importance of prioritizing client safety and effective nursing assessment in community health settings. Nurses must use critical thinking skills to determine the most appropriate course of action based on the client's needs and the situation at hand. Understanding the sequence of steps in addressing medication concerns is vital for providing quality care in community health nursing practice.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) explore the reasons for the client's forgetfulness. This option is the most appropriate first step because it allows the nurse to assess the underlying causes of the client's non-adherence to medication. By exploring the reasons behind the forgetfulness, the nurse can uncover potential barriers such as cognitive issues, financial constraints, lack of understanding, or side effects that may be contributing to the client's behavior. Option A) educate the client on the importance of medication adherence may be necessary, but it should come after understanding the client's reasons for forgetfulness. Simply providing education without addressing the root cause may not effectively improve adherence. Option C) providing the client with a pill organizer assumes that forgetfulness is the only issue at play and may not address the underlying reasons for non-adherence. Option D) adjusting the client's medication schedule should also come after exploring the reasons for forgetfulness to ensure that any changes made are appropriate and effective. In the context of community health nursing, it is essential to take a holistic and patient-centered approach to address medication adherence issues. By first exploring the reasons behind the forgetfulness, nurses can tailor interventions to best support the client in managing their hypertension effectively.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) assess the client's risk for falls. This is the most appropriate initial action for the nurse to take. By assessing the client's risk for falls, the nurse can address immediate safety concerns and prioritize interventions to prevent potential accidents or injuries. Option A) suggesting the client hires a cleaning service may address the cluttered environment but does not directly address the safety issue of falls. Option B) assisting the client in organizing the living space also focuses on the clutter but does not address the immediate risk of falls. Option D) providing the client with information on home safety is important but should come after assessing the specific risk factors present in the client's environment. Educationally, this question highlights the importance of prioritizing interventions based on the immediate needs of the client. Assessing risk factors is fundamental in developing a holistic and individualized care plan, especially in community health nursing where environmental factors play a significant role in overall health and safety. It is crucial for nurses to identify and address safety concerns proactively to promote the well-being of their clients.