Nursing Elites

1. A healthcare professional is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the healthcare professional take?

• A. Prime the blood tubing with normal saline.
• B. Verify the client’s identity using two identifiers.
• C. Infuse the blood rapidly over 30 minutes.
• D. Obtain the client’s vital signs every 4 hours during the transfusion.

Correct answer: B

Rationale: Verifying the client’s identity using two identifiers is a critical patient safety measure to ensure the correct patient receives the blood transfusion. This process involves checking the patient's identity using at least two unique identifiers, such as name, date of birth, or medical record number, to prevent administration errors. Priming the blood tubing with normal saline is necessary to ensure there are no air bubbles in the tubing, but it is not the immediate action required before administering the blood. Infusing packed red blood cells over 30 minutes is generally too rapid and can lead to adverse reactions; a slower rate is recommended for safe administration. Obtaining vital signs every 4 hours during the transfusion is not frequent enough to monitor the client adequately for potential transfusion reactions or complications; vital signs should be monitored more frequently, especially during the initial phase of the transfusion.

2. A client with chronic obstructive pulmonary disease (COPD) is prescribed theophylline. The nurse should monitor the client for which sign of theophylline toxicity?

• A. Drowsiness
• B. Bradycardia
• C. Nausea
• D. Constipation

Correct answer: C

Rationale: Nausea is an early sign of theophylline toxicity. The nurse should closely monitor the client for this symptom as it can progress to more severe toxicity. Nausea can be a warning sign to prevent further complications and adjust the dosage as necessary. Drowsiness (choice A) is a common side effect of theophylline but not a specific sign of toxicity. Bradycardia (choice B) and constipation (choice D) are not typically associated with theophylline toxicity. Therefore, the correct answer is C.

3. A client with a history of coronary artery disease (CAD) is being discharged with a prescription for aspirin. Which instruction should the nurse reinforce with the client?

• A. Take the aspirin on an empty stomach for better absorption.
• B. Stop taking the aspirin if you experience any stomach discomfort.
• C. Take the aspirin with food to reduce the risk of stomach irritation.
• D. Take the aspirin only when you have chest pain.

Correct answer: C

Rationale: The correct instruction is to take the aspirin with food to reduce the risk of stomach irritation. This is crucial for clients with a history of coronary artery disease as it helps minimize gastrointestinal side effects like irritation and bleeding. Option A is incorrect because aspirin should not be taken on an empty stomach to prevent stomach upset. Option B is incorrect because discontinuing aspirin at the first sign of stomach discomfort can be harmful, and a healthcare provider should be consulted instead. Option D is incorrect because aspirin is often prescribed for prevention in cardiovascular conditions, not just for chest pain relief.

4. A healthcare provider is reviewing the medication administration record of a client who has a latex allergy. Which of the following medications should the healthcare provider identify as a potential risk for an allergic reaction?

• A. Cefoxitin
• B. Amoxicillin
• C. Erythromycin
• D. Metronidazole

Correct answer: A

Rationale: The correct answer is A, Cefoxitin. Cefoxitin can contain latex in the stopper of the vial, which may pose a risk for allergic reaction in individuals with latex sensitivity. Amoxicillin, Erythromycin, and Metronidazole do not typically contain latex components in their formulations. Healthcare providers should be vigilant in identifying and avoiding medications with latex components to prevent adverse reactions in patients with known latex allergies.

5. The client with diabetes mellitus has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

• A. Restore skin integrity.
• B. Prevent infection.
• C. Promote healing.
• D. Improve nutrition.

Correct answer: B

Rationale: Preventing infection is crucial in clients with gangrene to halt the spread of infection and avert further complications. Infections can exacerbate tissue damage and lead to systemic complications, making infection prevention a priority in the care plan for this client. Restoring skin integrity and promoting healing may not be achievable goals until the infection is under control. Improving nutrition is important for overall health but may not be the priority when the immediate concern is preventing infection.

Similar Questions