Nursing Elites

1. A nurse is preparing a client for surgery. Which of the following actions should be taken first?

• A. Ensure informed consent is signed
• B. Start IV fluids
• C. Administer preoperative antibiotics
• D. Reinforce surgical site dressing

Correct answer: A

Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.

2. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?

• A. Administer acetaminophen
• B. Stop the transfusion
• C. Slow the transfusion rate
• D. Administer antihistamines

Correct answer: B

Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.

3. A client has a new prescription for folic acid and believes it's only for pregnant women. What statement should the nurse make?

• A. Folic acid is important only for pregnant women.
• B. You don’t need folic acid if you eat a balanced diet.
• C. Folic acid is important for the building of blood cells for adults and children.
• D. You should take folic acid only if your blood tests show a deficiency.

Correct answer: C

Rationale: The correct answer is C because folic acid is essential for the production of red blood cells in adults and children, not just for pregnant women. Option A is incorrect as folic acid is not exclusive to pregnant women. Option B is incorrect as a balanced diet may not provide sufficient folic acid. Option D is incorrect since folic acid supplementation is also recommended for other reasons beyond deficiency.

4. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

• A. Brachial pulse in the right arm
• B. Radial pulse in the right arm
• C. Brachial pulse in the left arm
• D. Radial pulse in the left arm

Correct answer: D

Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.

5. A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following a total hysterectomy. Which of the following information should the nurse include?

• A. Take at different times of the day
• B. Prevents from having a cerebral hemorrhage
• C. Prevents osteoporotic fractures
• D. Take an extra dose if missed a day

Correct answer: C

Rationale: The correct information the nurse should include is that menopausal hormone therapy helps prevent osteoporotic fractures by maintaining bone density. Option A is incorrect as hormone therapy should be taken consistently at the same time each day for optimal effectiveness. Option B is incorrect as menopausal hormone therapy is not primarily aimed at preventing cerebral hemorrhage. Option D is incorrect because taking an extra dose is not recommended if a dose is missed; instead, the missed dose should be taken as soon as remembered, unless it is close to the time for the next dose.

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