Nursing Elites

1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as an indication of a hemolytic transfusion reaction?

• A. Low back pain.
• B. Bradycardia.
• C. Chills.
• D. Distended neck veins.

Correct answer: A

Rationale: The correct answer is A: Low back pain. Low back pain is a common sign of a hemolytic transfusion reaction, indicating the destruction of red blood cells. This finding requires immediate intervention as it can lead to serious complications such as renal failure. Bradycardia (choice B) is not typically associated with a hemolytic transfusion reaction. Chills (choice C) can be seen in febrile non-hemolytic transfusion reactions. Distended neck veins (choice D) are more indicative of fluid overload rather than a hemolytic reaction.

2. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Auscultate the newborn's apical pulse for 60 seconds
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence

Correct answer: C

Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.

3. Which medication is commonly prescribed for a patient with a history of heart failure?

• A. Furosemide
• B. Metoprolol
• C. Digoxin
• D. Aspirin

Correct answer: A

Rationale: Furosemide is the correct answer. It is a common diuretic used in patients with heart failure to reduce fluid overload. Metoprolol (Choice B) is a beta-blocker often prescribed to manage heart failure symptoms by improving heart function. Digoxin (Choice C) is used in heart failure patients to help the heart beat stronger and with a more regular rhythm. Aspirin (Choice D) is not typically prescribed for heart failure but may be used in patients with heart disease for its antiplatelet effects.

4. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes mellitus. Which of the following client statements indicates a need for further teaching?

• A. I will check my blood glucose level once a week.
• B. I will eat a snack if my blood glucose level is above 200 mg/dL.
• C. I will take my insulin as prescribed, even when I am feeling well.
• D. I will avoid physical activity if my blood glucose level is below 100 mg/dL.

Correct answer: B

Rationale: The correct answer is B. Clients should eat a snack when their blood glucose level is low, typically below 70-100 mg/dL, not when it is high. Eating a snack when the blood glucose level is above 200 mg/dL can exacerbate hyperglycemia. Choice A is correct as checking blood glucose levels regularly is important in managing diabetes. Choice C is also correct as adherence to prescribed insulin therapy is crucial. Choice D is incorrect as physical activity can help lower blood glucose levels, especially when they are above the target range.

5. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Ensure the client has access to legal services.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

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