Nursing Elites

1. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?

• A. Elevate the head of the client's bed to 45 degrees
• B. Have another nurse call the Rapid Response Team
• C. Prepare to administer diphenhydramine (Benadryl)
• D. Slow the rate of the IV infusion

Correct answer: B

Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.

2. A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?

• A. Airborne
• B. Standard
• C. Contact
• D. Droplet

Correct answer: A

Rationale: The correct answer is 'Airborne.' Varicella (chickenpox) is caused by the varicella-zoster virus, which spreads through the air by respiratory droplets. Therefore, placing the client on airborne precautions is necessary to prevent the transmission of the virus. Choice B, 'Standard precautions,' involve basic infection prevention measures that are used for all client care. Choice C, 'Contact precautions,' are used for diseases that spread by direct or indirect contact. Choice D, 'Droplet precautions,' are implemented for diseases transmitted by respiratory droplets that are larger than 5 microns.

3. The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?

• A. Administer prescribed diphenhydramine (Benadryl).
• B. Continue to monitor the client's vital signs.
• C. Stop the infusion of packed red blood cells.
• D. Slow the infusion rate of the transfusion

Correct answer: D

Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.

4. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

• A. Poor left-sided motor control
• B. Paralysis or contractures on the right side
• C. Limited visual perception of the left fields
• D. Unawareness of the existence of her left side

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

5. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select one that doesn't apply.)

• A. Use sterile gloves and gowns whenever the nursing staff is in contact with the client.
• B. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only
• C. Request that the family take home the fresh flowers that are at the client's bedside
• D. Assist the client with meticulous oral care after meals and at bedtime.

Correct answer: A

Rationale:

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