Nursing Elites

1. A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse’s priority action?

• A. Administer pain medication.
• B. Lay the client flat and notify the healthcare provider.
• C. Encourage the client to drink more fluids.
• D. Assess the client’s surgical site for drainage.

Correct answer: B

Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.

2. A client with uterine cancer asks the nurse, 'Which is the most common type of cancer in women?' The nurse replies that it is breast cancer. Which type of cancer causes the most deaths in women?

• A. Breast cancer
• B. Lung cancer
• C. Brain cancer
• D. Colon and rectal cancer

Correct answer: B

Rationale: Lung cancer is the leading cause of cancer-related deaths in women, surpassing even breast cancer. While breast cancer is more common, it is often detected early enough for effective treatment. Lung cancer, on the other hand, tends to be diagnosed at later stages, leading to higher mortality rates. Brain cancer and colon and rectal cancer are not the leading causes of cancer-related deaths in women, making them incorrect choices.

3. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?

• A. The newborn is infected with an infectious blood-borne disease
• B. The newborn needs phototherapy for physiologic jaundice
• C. The mother's Rh antibodies are present in the neonatal blood
• D. The mother no longer needs Rho immune globulin injections

Correct answer: C

Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.

4. Which action should the PN implement when using standard precautions to provide client care?

• A. Apply sterile gloves to obtain a finger stick blood sample
• B. Wear clean exam gloves to perform perineal catheter care
• C. Replace the needle cap after giving an intramuscular injection
• D. Wear a paper gown to prevent transmission of droplet pathogens

Correct answer: B

Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.

5. What is an essential nursing action before administering a blood transfusion?

• A. Checking the patient’s blood pressure
• B. Verifying the blood type and patient identity with another nurse
• C. Flushing the IV line with saline
• D. Administering pre-transfusion medications

Correct answer: B

Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.

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