Nursing Elites

1. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.

2. A client has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

• A. Inject 5 units of air into the bottle of regular insulin
• B. Withdraw the correct dose of NPH insulin from the bottle
• C. Inject 10 units of air into the bottle of NPH insulin
• D. Withdraw the correct dose of regular insulin from the bottle

Correct answer: B

Rationale: The correct order of steps for this procedure is to first inject air into the NPH insulin bottle to prevent vacuum formation. After injecting air into the NPH insulin, the next step is to withdraw the correct dose of regular insulin from its bottle. This sequence ensures that the regular insulin is drawn after the NPH insulin, preventing contamination and ensuring accurate dosing. Therefore, choice B is correct. Choices A, C, and D are incorrect because air should be injected into the NPH insulin first, not the regular insulin, and the doses should be withdrawn in the appropriate order to maintain the integrity and potency of each insulin type.

3. The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?

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

Correct answer: C

Rationale: Contact precautions are necessary when caring for a client with a wound infection to prevent the spread of infection. Contact precautions involve practices such as wearing gloves and gowns, and ensuring proper hand hygiene. Airborne precautions are for diseases transmitted by small droplet nuclei that can remain suspended in the air, like tuberculosis. Droplet precautions are for diseases transmitted through respiratory droplets larger than 5 microns, such as influenza. Standard precautions are used for all clients to prevent the spread of infection and include practices like hand hygiene, use of personal protective equipment, and safe injection practices. In this case, since the client has a wound infection, the nurse should focus on implementing contact precautions to reduce the risk of spreading the infection to themselves or others.

4. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy site with hydrogen peroxide daily.
• C. Change the tracheostomy tube weekly.
• D. Apply ointment around the tracheostomy site.

Correct answer: A

Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.

5. A client is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

• A. Hemolytic
• B. Allergic
• C. Febrile
• D. Transfusion-related acute lung injury (TRALI)

Correct answer: A

Rationale: The correct answer is A: Hemolytic. Hemolytic reactions can lead to flank pain and hemoglobinuria, as the body breaks down the transfused red blood cells. In hemolytic reactions, the immune system attacks and destroys the transfused red blood cells, causing the release of hemoglobin into the bloodstream and urine. This results in reddish-brown urine, indicating hemoglobinuria. Allergic reactions typically present with symptoms like itching, hives, or rash. Febrile reactions are characterized by fever, chills, and rigors. TRALI is a rare but serious transfusion reaction that manifests as acute respiratory distress following a transfusion, not flank pain and hemoglobinuria.

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