Nursing Elites

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

• A. Low back pain
• B. Distended neck veins
• C. Chills and fever
• D. Headache

Correct answer: C

Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.

2. A patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain?

• A. Meditation alters the chemical composition of pain neuroregulators, which closes the gate.
• B. Meditation stops the occurrence of pain stimuli.
• C. Meditation controls pain by blocking pain impulses from coming through the gate.
• D. Meditation will help me sleep through the pain because it opens the gate.

Correct answer: C

Rationale: The correct answer is C. According to the gate control theory, meditation helps relieve pain by blocking pain impulses from coming through the gate in the central nervous system. Choice A is incorrect as meditation does not directly alter the chemical composition of pain neuroregulators. Choice B is incorrect because meditation does not stop the occurrence of pain stimuli. Choice D is incorrect as meditation does not open the gate but rather closes it to block pain impulses.

3. A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

• A. Increase the dosage of pain medication.
• B. Assess for compartment syndrome.
• C. Wait for the healthcare provider to address the issue.
• D. Reposition the client to alleviate the pain.

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

4. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

5. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?

• A. I will double my dose if I miss one
• B. I should take this medication on an empty stomach between meals
• C. I will take the medication until my sore throat goes away
• D. I will stop taking this medication if I develop itching

Correct answer: C

Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.

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