Nursing Elites

1. A nurse is caring for a client who is receiving packed RBCs. Which of the following actions should the nurse take?

• A. Monitor the client's blood glucose level every hour
• B. Administer the blood using a microdrip set
• C. Assess the client's vital signs every 2 hours
• D. Infuse the blood within 4 hours

Correct answer: D

Rationale: The correct answer is to infuse the blood within 4 hours. This is crucial to prevent bacterial contamination and hemolysis during blood transfusions. Monitoring the client's blood glucose level every hour (Choice A) is not directly related to packed RBC transfusions. Administering the blood using a microdrip set (Choice B) may be appropriate for specific medications but is not a requirement for packed RBC transfusions. Assessing the client's vital signs every 2 hours (Choice C) is important for monitoring the client's overall condition but is not as time-sensitive as ensuring the timely infusion of packed RBCs.

2. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?

• A. First-degree AV block.
• B. Premature ventricular contraction.
• C. Sinus bradycardia.
• D. Atrial fibrillation.

Correct answer: A

Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.

3. A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?

• A. Take medication at bedtime.
• B. Check blood pressure once a week.
• C. Use a blood pressure cuff that fits snugly around the arm.
• D. Stop taking medication once blood pressure is within the normal range.

Correct answer: C

Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.

4. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30 degrees.
• B. Check gastric residual volumes every 4 hours.
• C. Administer the feeding at room temperature.
• D. Flush the feeding tube with 20 mL of water every 8 hours.

Correct answer: B

Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.

5. A client with a new prescription for levothyroxine is receiving discharge teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication with food to prevent nausea.
• B. I will take this medication every morning before breakfast.
• C. I will stop taking this medication if I experience chest pain.
• D. I will take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken every morning before breakfast to enhance absorption and maintain consistent thyroid hormone levels. Option A is incorrect because levothyroxine should be taken on an empty stomach. Option C is incorrect because chest pain is not a common side effect of levothyroxine and stopping the medication abruptly can be harmful. Option D is incorrect because taking levothyroxine at bedtime may result in decreased absorption due to interactions with food and other medications.

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