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 client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?

• A. Improved tolerance to cold.
• B. Decreased fatigue and improved energy levels.
• C. Reduced anxiety and improved mood.
• D. Increased sensitivity to heat.

Correct answer: B

Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.

3. A client receiving chemotherapy reports severe nausea. What should the nurse implement first?

• A. Administer an antiemetic as prescribed.
• B. Offer the client small, frequent meals.
• C. Provide the client with crackers and water.
• D. Encourage the client to eat a bland diet.

Correct answer: A

Rationale: The correct answer is A: Administer an antiemetic as prescribed. When a client receiving chemotherapy reports severe nausea, the priority action is to administer an antiemetic medication as prescribed. Antiemetics help alleviate nausea and prevent complications associated with chemotherapy, such as dehydration and malnutrition. Options B, C, and D focus on dietary interventions which can be helpful but addressing the severe nausea with antiemetic medication takes precedence to provide immediate relief and ensure the client's comfort and well-being.

4. The nurse is caring for a client with a history of congestive heart failure (CHF) who is receiving digoxin therapy. The client reports seeing halos around lights. Which action should the nurse take?

• A. Assess the client's digoxin level
• B. Increase the client's fluid intake
• C. Check the client's blood pressure
• D. Administer a dose of potassium

Correct answer: A

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity. The nurse should assess the client's digoxin level to determine if the dose needs to be adjusted or if the medication should be held. Increasing fluid intake or checking blood pressure would not directly address the symptom of halos around lights. Administering a dose of potassium is not indicated without knowing the digoxin level and could potentially worsen the toxicity.

5. A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?

• A. Monitor for clear fluid leakage from the nose.
• B. Assess for rapid onset of decreased level of consciousness.
• C. Check for bruising around the head and neck.
• D. Assess for changes in pupil size and reactivity.

Correct answer: B

Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.

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