Nursing Elites

1. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?

• A. The client suddenly complains of back pain and has chills
• B. The client develops dependent edema in the extremities
• C. The client has a seizure
• D. The client's heart rate drops to 60 bpm

Correct answer: A

Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.

2. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

3. In the term 'Hemoglobin,' the suffix '-globin' means:

• A. Protein
• B. Iron
• C. Metal
• D. Blood

Correct answer: A

Rationale: The suffix '-globin' in the term 'Hemoglobin' specifically refers to a protein. Hemoglobin is a protein found in red blood cells that carries oxygen. Choice B, 'Iron,' is incorrect as iron is a mineral component of hemoglobin but not the meaning of the suffix. Choice C, 'Metal,' is too broad and not specific to the meaning of the suffix in this context. Choice D, 'Blood,' is incorrect as it refers to the overall term 'Hemoglobin' rather than the specific meaning of the suffix '-globin.' Therefore, the correct answer is A: 'Protein.'

4. Which of the following scenarios provides an example of a healthcare professional overcoming a barrier to communication?

• A. A healthcare professional uses a visual aid to explain how to conduct a fingerstick glucose test to a patient with visual impairment.
• B. A healthcare professional writes down instructions for a patient who is hearing impaired.
• C. A healthcare professional raises their voice when speaking to a patient who does not speak English.
• D. A healthcare professional uses medical jargon while conversing with a minor.

Correct answer: B

Rationale: Overcoming barriers to communication in healthcare involves utilizing methods of communication that are accessible and understandable to the recipient. In the scenario provided, writing down instructions for a patient who is hearing impaired is an effective way to ensure clear communication and overcome the obstacle of hearing impairment. This method allows the patient to visually comprehend the information provided. Choice A is incorrect because using a visual aid for a visually impaired patient, not a hearing-impaired patient, would be more appropriate. Choice C is incorrect as raising one's voice does not address the language barrier effectively and may not enhance understanding. Choice D is incorrect as using complex medical terms with a minor may lead to confusion and hinder effective communication.

5. Why should a palpated pressure be performed before auscultating blood pressure?

• A. To more clearly hear the Korotkoff sounds.
• B. To detect the presence of an auscultatory gap.
• C. To avoid missing a falsely elevated blood pressure.
• D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

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