Nursing Elites

1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a hemolytic transfusion reaction?

• A. Chills
• B. Bradycardia
• C. Hypertension
• D. Low back pain

Correct answer: D

Rationale: Low back pain is a classic sign of a hemolytic transfusion reaction and requires immediate intervention. Chills are more commonly associated with a febrile non-hemolytic transfusion reaction. Bradycardia is not a typical sign of a hemolytic transfusion reaction. Hypertension is not a common finding in a hemolytic transfusion reaction.

2. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?

• A. A Braden scale score of 20
• B. An albumin level of 3 g/dL
• C. A hemoglobin level of 13 g/dL
• D. A Norton scale score of 18

Correct answer: B

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.

3. How can a healthcare professional reduce the risk of falls in elderly patients?

• A. Encourage the use of assistive devices.
• B. Clear walkways.
• C. Ensure proper lighting.
• D. All of the above.

Correct answer: D

Rationale: All of these interventions are crucial in reducing the risk of falls in elderly patients. Encouraging the use of assistive devices helps provide support and stability, clearing walkways minimizes tripping hazards, and ensuring proper lighting enhances visibility and reduces the chances of falls. Therefore, choosing 'All of the above' is the most appropriate answer as each intervention plays a significant role in fall prevention.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

• A. Administer the TPN through a peripheral IV catheter.
• B. Check the client's capillary blood glucose level every 4 hours.
• C. Heat the TPN solution to room temperature before administering.
• D. Weigh the client every 3 days.

Correct answer: B

Rationale: The correct answer is to check the client's capillary blood glucose level every 4 hours. Clients receiving TPN are at risk for hyperglycemia, so regular monitoring of blood glucose levels is essential to detect and manage hyperglycemia promptly. Administering TPN through a peripheral IV catheter (Choice A) is incorrect as TPN should be given through a central venous catheter to prevent complications. Heating the TPN solution to room temperature (Choice C) is unnecessary and not a standard practice. Weighing the client every 3 days (Choice D) is important for monitoring fluid status but is not the priority action when caring for a client receiving TPN.

5. A client who is 1 day postoperative following a total hip arthroplasty should be instructed to do which of the following?

• A. Avoid using a walker while walking.
• B. Keep the hip flexed at 90° while sitting.
• C. Place a pillow between your legs when turning.
• D. Cross your legs at the ankles when sitting.

Correct answer: C

Rationale: Placing a pillow between the legs is essential post-total hip arthroplasty to prevent adduction of the hip joint, reducing the risk of dislocation. Choices A, B, and D are incorrect. Using a walker while walking is encouraged for support and stability. Keeping the hip flexed at 90° while sitting can increase the risk of hip dislocation. Crossing legs at the ankles when sitting may also lead to hip dislocation.

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