Nursing Elites

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

• A. Stop the transfusion and notify the healthcare provider.
• B. Monitor the client's vital signs every 15 minutes.
• C. Administer a PRN dose of diphenhydramine.
• D. Prepare to administer an antihistamine.

Correct answer: A

Rationale: The correct first action for the nurse is to stop the transfusion and notify the healthcare provider. These symptoms suggest a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Notifying the healthcare provider ensures timely intervention and appropriate management for the client's condition. Monitoring vital signs, administering diphenhydramine, or preparing to administer an antihistamine can be considered after stopping the transfusion and seeking guidance from the healthcare provider. However, the immediate priority is to halt the transfusion and inform the provider.

2. A male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?

• A. Instruct the client to increase oral fluid intake.
• B. Reassure the client that flushing is a common side effect.
• C. Advise the client to take nitroglycerin as a precaution.
• D. Ask the client to come to the emergency room.

Correct answer: B

Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.

3. A client with deep vein thrombosis (DVT) is receiving heparin and reports tarry stools. What should the nurse do?

• A. Prepare to administer warfarin.
• B. Assess characteristics of the client's pain.
• C. Monitor stools for blood and review PTT results.
• D. Continue the heparin and prepare to administer Vitamin K.

Correct answer: C

Rationale: When a client on heparin reports tarry stools, it can be indicative of gastrointestinal bleeding. The correct action for the nurse is to monitor the stools for blood and review the Partial Thromboplastin Time (PTT) results. This is essential to detect any potential bleeding complications associated with heparin therapy. Option A is incorrect because warfarin is not the immediate intervention for tarry stools in a client on heparin. Option B is irrelevant to the situation described. Option D is incorrect as Vitamin K is the antidote for warfarin, not heparin.

4. A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?

• A. Administer a PRN dose of corticosteroids.
• B. Place the client in a supine position.
• C. Encourage oral fluid intake.
• D. Review the client's recent medication history.

Correct answer: A

Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.

5. A client with hyperkalemia is receiving insulin and glucose. Which laboratory value should the nurse monitor closely?

• A. Monitor the client's blood glucose level.
• B. Monitor the client's sodium level.
• C. Monitor the client's calcium level.
• D. Monitor the client's potassium level.

Correct answer: D

Rationale: The correct answer is to monitor the client's potassium level. When administering insulin and glucose in hyperkalemia, the aim is to shift potassium from the bloodstream into the cells, lowering elevated levels. Therefore, monitoring potassium levels closely is essential to prevent hypokalemia or further complications. Monitoring blood glucose levels (Choice A) is important but not the priority in this scenario. Monitoring sodium (Choice B) and calcium levels (Choice C) is not directly related to the treatment of hyperkalemia with insulin and glucose.

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