The nurse is caring for clients in a rural health clinic and wants to promote illness prevention. Which action should the nurse take?

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Question 1 of 5

The nurse is caring for clients in a rural health clinic and wants to promote illness prevention. Which action should the nurse take?

Correct Answer: A

Rationale: In a rural clinic, illness prevention primary prevention aims to stop disease before it starts, critical where access lags. Providing accident prevention education, like safe tractor use or fall risks, targets common rural hazards, reducing injuries proactively. Screening for hypertension is secondary, detecting issues, not preventing them. Referring chronic cases to specialists or teaching diabetic diets is tertiary, managing existing conditions, not averting onset. Accident prevention fits rural needs data shows higher injury rates in such areas empowering clients with knowledge to avoid harm. The nurse's action aligns with nursing's preventive role, addressing environmental and lifestyle risks unique to the setting, enhancing community health by tackling root causes before they escalate, a practical step given limited rural resources.

Question 2 of 5

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

Correct Answer: A

Rationale: A high-pressure alarm on a ventilator indicates obstruction or resistance, often from secretions; suctioning (A) is the priority to clear the airway. Checking for disconnection (B) fits low-pressure alarms. Notifying respiratory therapy (C) delays action. Evaluating the cuff (D) addresses leaks, not high pressure. A is correct. Rationale: Suctioning resolves common causes like mucus plugs, restoring ventilation swiftly, a first-line action per ventilator management protocols, critical to prevent hypoxia or barotrauma.

Question 3 of 5

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Correct Answer: A

Rationale: Post-extubation after radical neck dissection, stridor (A) indicates airway obstruction (e.g., edema, laryngospasm), requiring immediate RN reporting. Lung congestion (B) or pink sputum (C) suggest fluid but are less urgent. A rate of 26 (D) is elevated but not critical alone. A is correct. Rationale: Stridor signals potential airway compromise, a life-threatening emergency post-neck surgery due to swelling or structural changes, necessitating rapid intervention like reintubation or steroids, per post-operative care standards, unlike less acute findings.

Question 4 of 5

When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?

Correct Answer: D

Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.

Question 5 of 5

A client with a traumatic brain injury is receiving mannitol. The nurse should monitor for which adverse effect of this medication?

Correct Answer: A

Rationale: Mannitol, an osmotic diuretic, can cause hypotension (A) from fluid shifts and diuresis. Hyperkalemia (B), hyperglycemia (C), or bradycardia (D) are less common. A is correct. Rationale: BP drop risks perfusion; monitoring ensures safety, per pharmacology, critical in brain injury management.

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