Nursing Elites

1. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

2. A client with hypertension is prescribed a beta-blocker. What teaching should the nurse provide about this medication?

• A. Instruct the client to avoid high-potassium foods.
• B. Monitor the client’s heart rate and report any bradycardia.
• C. Advise the client to rise slowly from a sitting or lying position.
• D. Instruct the client to avoid sudden position changes.

Correct answer: C

Rationale: The correct answer is to advise the client to rise slowly from a sitting or lying position. Beta-blockers can cause bradycardia and hypotension, so clients should be advised to rise slowly to prevent dizziness and falls. Monitoring the client's heart rate and blood pressure regularly is essential. Instructing the client to avoid high-potassium foods (Choice A) is not directly related to beta-blockers. While monitoring the client's heart rate (Choice B) is important, advising the client to rise slowly (Choice C) is more directly related to potential side effects of beta-blockers. Instructing the client to avoid sudden position changes (Choice D) is not as specific or essential as advising them to rise slowly to prevent adverse effects.

3. A client is receiving morphine for postoperative pain. What is the nurse's priority assessment?

• A. Monitor the client's respiratory rate.
• B. Monitor the client's level of consciousness.
• C. Assess the client's level of pain.
• D. Monitor the client's blood pressure.

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to detect this potential side effect early. Monitoring the client's level of consciousness (Choice B) is important but comes after ensuring adequate breathing. Assessing the client's pain level (Choice C) is essential but not the priority when dealing with the side effects of morphine. Monitoring the client's blood pressure (Choice D) is also important but not the priority assessment when the focus is on respiratory depression.

4. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?

• A. Monitor potassium levels.
• B. Monitor sodium levels.
• C. Monitor calcium levels.
• D. Monitor magnesium levels.

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

5. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?

• A. Limit sodium intake to reduce fluid retention
• B. Consume high-protein foods to strengthen the heart
• C. Increase potassium intake to manage blood pressure
• D. Increase fluid intake to promote hydration

Correct answer: A

Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.

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