Nursing Elites

1. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?

• A. Obtain the client's vital signs.
• B. Ensure the client's IV access is patent.
• C. Prime the IV tubing with 0.9% sodium chloride.
• D. Verify the client's identity.

Correct answer: D

Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.

2. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?

• A. Perform an ECG every 12 hours
• B. Place the client in a supine position while resting
• C. Draw a troponin level every 4 hours
• D. Obtain a cardiac rehabilitation consultation

Correct answer: D

Rationale: After an acute myocardial infarction, it is important to involve the client in cardiac rehabilitation to help them recover and manage their condition effectively. Performing an ECG every 12 hours is not necessary unless there are specific indications for it. Placing the client in a supine position may not be ideal as it can increase venous return, potentially worsening cardiac workload. Drawing troponin levels every 4 hours is excessive and not recommended as troponin levels usually peak within 24-48 hours post-MI and then gradually decline.

3. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

4. What is the priority nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Perform a neurological exam

Correct answer: A

Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.

5. A nurse is reviewing the laboratory results of a client who has hypocalcemia. Which of the following findings should the nurse expect?

• A. Positive Trousseau's sign
• B. Increased deep tendon reflexes
• C. Hyperactive bowel sounds
• D. Weak, thready pulse

Correct answer: A

Rationale: A positive Trousseau's sign is a key finding in clients with hypocalcemia, indicating neuromuscular irritability. The other choices are not typically associated with hypocalcemia. Increased deep tendon reflexes are more indicative of hypercalcemia. Hyperactive bowel sounds can be seen in hyperactive bowel conditions or diarrhea, not specifically related to hypocalcemia. A weak, thready pulse may indicate cardiovascular issues, such as dehydration, but it is not a typical finding in hypocalcemia.

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