Nursing Elites

1. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

2. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow the rate of transfusion.
• B. Administer an antipyretic.
• C. Stop the transfusion immediately.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

3. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

• A. Explain that all staff are doing their best
• B. Ask for a description of what happened during the night
• C. Tell the daughter to talk to the unit's nurse manager
• D. Reassure the daughter that the mother will get better care

Correct answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

4. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?

• A. The IV fluids are infusing into the subcutaneous tissues
• B. The infusion pump is functioning properly
• C. The insertion date should be verified and the IV discontinued
• D. The site is inflamed and should be reported

Correct answer: B

Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.

5. A client with a history of seizures is being discharged home. Which instruction is most important for the nurse to provide?

• A. Take your medication as prescribed.
• B. Avoid driving until your condition is stable.
• C. Keep a seizure diary.
• D. Avoid alcohol consumption.

Correct answer: A

Rationale: The most important instruction for a client with a history of seizures being discharged home is to take their medication as prescribed. Consistent and timely intake of anti-seizure medication is vital in managing seizures and preventing episodes. While instructions like avoiding driving until the condition is stable, keeping a seizure diary, and avoiding alcohol consumption are important, none are as critical as ensuring proper medication adherence to control seizures effectively. Failure to take prescribed medications can lead to breakthrough seizures, compromising the patient's safety and seizure control.

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