Nursing Elites

1. A client is receiving a blood transfusion and develops a fever. What is the nurse's first action?

• A. Administer an antipyretic as prescribed.
• B. Stop the transfusion and notify the healthcare provider.
• C. Slow the rate of the transfusion.
• D. Continue the transfusion and reassess in 15 minutes.

Correct answer: B

Rationale: The correct first action when a client receiving a blood transfusion develops a fever is to stop the transfusion and notify the healthcare provider. This is crucial to prevent further reactions and ensure prompt intervention. Administering an antipyretic (Choice A) may mask symptoms and delay appropriate treatment. Slowing the rate of the transfusion (Choice C) might not address the underlying cause of the fever. Continuing the transfusion and reassessing in 15 minutes (Choice D) could worsen the client's condition if there is a severe reaction occurring.

2. A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What client teaching is essential?

• A. Increase fluid intake to prevent crystalluria.
• B. Take the medication with meals to prevent GI upset.
• C. Avoid sunlight exposure while taking the medication.
• D. Report any changes in the color of urine.

Correct answer: A

Rationale: The correct answer is to increase fluid intake to prevent crystalluria, a potential side effect of ciprofloxacin. Crystalluria is the formation of crystals in the urine, which can be reduced by maintaining adequate hydration. Choice B is incorrect because ciprofloxacin can be taken with or without food. Choice C is incorrect as avoiding sunlight exposure is more relevant for medications that cause photosensitivity, not typically a concern with ciprofloxacin. Choice D is less essential than choice A because while reporting changes in urine color is important, preventing crystalluria through adequate fluid intake is a higher priority.

3. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?

• A. Apply compression therapy to the affected leg
• B. Keep the affected leg in a dependent position
• C. Massage the area surrounding the ulcer
• D. Encourage the client to elevate the leg for 2 hours daily

Correct answer: A

Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.

4. The nurse is caring for a seated client experiencing a tonic-clonic seizure. Which actions should the nurse implement?

• A. Place a padded tongue depressor in the client's mouth
• B. Restrain the client and attempt to stop the seizure
• C. Begin CPR immediately
• D. Loosen restrictive clothing and ease the client to the floor

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse should loosen restrictive clothing to prevent injury and ease the client to the floor to ensure safety. Placing any object, such as a tongue depressor, in the client's mouth is contraindicated as it may cause harm. Restraint should not be used as it can lead to injury. Beginning CPR is not indicated during a seizure unless the client experiences cardiac arrest, which is a rare complication of seizures.

5. A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?

• A. Prepare to administer protamine sulfate.
• B. Continue the heparin infusion and notify the healthcare provider.
• C. Monitor the client's vital signs and assess abdominal pain.
• D. Administer a PRN dose of morphine sulfate.

Correct answer: A

Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.

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