Nursing Elites

1. The client is going for surgery and mentions their religious objection to blood transfusions. Which of the following responses would be most appropriate?

• A. "I can ask pastoral care to send someone to speak with you about this concern since it would not be safe to refuse a blood transfusion."?
• B. "I understand, and you have the right to refuse blood transfusions."?
• C. "While I understand, if there is excessive bleeding during surgery, we may need to transfuse blood to stabilize you."?
• D. "I have received a blood transfusion before, and I do not think you understand the risks versus the benefits of refusing this."?

Correct answer: B

Rationale: The most appropriate response is, '"I understand, and you have the right to refuse blood transfusions."? This answer shows respect for the client's autonomy and religious beliefs. It is crucial for healthcare providers to acknowledge and support a patient's decision-making regarding their care, even if it conflicts with medical advice. Option A is not ideal as it might seem dismissive of the client's beliefs. Option C introduces a potential negative outcome of refusing a blood transfusion, which could induce fear or coercion. Option D is inappropriate because it implies judgment and does not uphold the client's autonomy.

2. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.

• A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
• B. The client had an allergy to cefazolin sodium.
• C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
• D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

Correct answer: D

Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.

3. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?

• A. Retape the NG tube.
• B. Clamp the NG tube.
• C. Remove the NG tube.
• D. Check the NG tube placement.

Correct answer: D

Rationale: When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (Choice A), clamping it (Choice B), or removing it (Choice C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (Choice A) is incorrect because the priority is to check the placement first. Clamping the NG tube (Choice B) or removing it (Choice C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.

4. All of the following are causes of vaginal bleeding in late pregnancy except:

• A. Placenta previa.
• B. Eclampsia.
• C. Abruptio placentae.
• D. Uterine rupture.

Correct answer: B

Rationale: The correct answer is B: Eclampsia. Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizures and/or coma but does not typically present with vaginal bleeding. Choices A, C, and D are abnormal conditions that can cause bleeding, particularly in the third trimester. Placenta previa (choice A) is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. Abruptio placentae (choice C) is the premature separation of the placenta from the uterine wall, causing vaginal bleeding. Uterine rupture (choice D) is a serious obstetrical emergency where the uterus tears during pregnancy or childbirth, resulting in severe bleeding.

5. Which of the following is not one of the four categories related to client care plans?

• A. privacy
• B. evaluation
• C. diagnosis
• D. outcome

Correct answer: A

Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.

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