Nursing Elites

1. A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?

• A. packed red blood cells
• B. platelets
• C. plasma
• D. granulocytes

Correct answer: A

Rationale: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.

2. Which statement reflects a primary belief of psychiatric mental health nursing?

• A. Most people have the potential to change and grow.
• B. Every person is worthy of dignity and respect.
• C. Human needs are individual to each person.
• D. Some behaviors have no meaning and cannot be understood.

Correct answer: B

Rationale: The correct answer reflects a primary belief of psychiatric mental health nursing, which is that every person is worthy of dignity and respect. This belief forms the foundation of providing holistic and compassionate care in mental health nursing. While it is true that most people have the potential to change and grow, this choice does not directly address a core belief of mental health nursing. Human needs being individual to each person is a general principle of nursing care but does not specifically capture a primary belief in psychiatric mental health nursing. The statement that some behaviors have no meaning and cannot be understood contradicts the fundamental principle that all behavior has meaning and can be understood from the client's perspective in psychiatric mental health nursing.

3. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

• A. Assessment of the client's level of anxiety
• B. Evaluation of the client's exercise tolerance
• C. Identification of peripheral pulses
• D. Assessment of bowel sounds and activity

Correct answer: C

Rationale: The most crucial assessment during the preoperative period for a client scheduled for surgical repair of a sacular abdominal aortic aneurysm is the identification of peripheral pulses. This is essential because during surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Monitoring peripheral pulses helps assess circulation to the lower extremities, ensuring adequate perfusion. While assessing the client's anxiety level (choice A) is important, it is not as critical as monitoring peripheral pulses in this case. Evaluating exercise tolerance (choice B) is not typically recommended preoperatively for this specific condition. Assessing bowel sounds and activity (choice D) is also relevant but takes a lower priority compared to identifying peripheral pulses in this scenario.

4. The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?

• A. right to refuse treatment
• B. right to continuity of care
• C. right to confidentiality
• D. right to reasonable responses to requests

Correct answer: C

Rationale: The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. In this scenario, discussing a client scenario in a public elevator could potentially lead to the breach of the client's right to confidentiality. The other choices, such as the right to refuse treatment, right to continuity of care, and right to reasonable responses to requests, are not typically breached in this context. It is important to uphold client confidentiality to maintain trust and privacy in healthcare settings.

5. A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:

• A. the client's body has developed tolerance, requiring more drug to produce the same effect.
• B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence.
• C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance.
• D. the client has a dual diagnosis of substance abuse and chronic back pain

Correct answer: A

Rationale: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effects and decreased sensitivity to the substance. In this scenario, the client needing an increased dose of hydrocodone to achieve the same pain relief indicates tolerance developing, not addiction. Choice B is incorrect as it describes drug dependence, where the individual is preoccupied with the drug and has a loss of control. Choice C is incorrect because addiction involves psychological behaviors related to substance use, not just physical dependence with withdrawal symptoms and tolerance. Choice D is incorrect as it refers to a dual diagnosis, which is the coexistence of substance abuse and psychiatric disorders, not the development of tolerance to a drug.

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