Nursing Elites

1. A healthcare provider is preparing to administer a vaccine to a child. Which of the following should the provider verify?

• A. Allergy to eggs
• B. Previous vaccination history
• C. Family medical history
• D. Growth charts

Correct answer: B

Rationale: The healthcare provider should verify the child's previous vaccination history to ensure they are up to date with immunizations. This is important to prevent unnecessary or duplicate vaccinations and ensure the child is adequately protected against vaccine-preventable diseases. Checking for allergies to eggs is relevant for certain vaccines like the influenza vaccine but is not the top priority in this scenario. Family medical history and growth charts are not directly related to the administration of vaccines and are not as crucial as confirming the child's vaccination status.

2. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

• A. Administer an antihistamine prior to transfusion.
• B. Check the client’s vital signs.
• C. Verify the client’s identification with another nurse.
• D. Prime the IV tubing with normal saline.

Correct answer: C

Rationale: The correct first action the nurse should take when preparing to administer packed RBCs to a client is to verify the client’s identification with another nurse. This is crucial to ensure that the correct blood product is administered to the correct client, minimizing the risk of a transfusion reaction. Administering an antihistamine prior to transfusion (Choice A) is not the first priority and is not a standard practice. While checking the client’s vital signs (Choice B) is important, verifying the client’s identification takes precedence to prevent a critical error. Priming the IV tubing with normal saline (Choice D) is a necessary step in the process but should occur after verifying the client's identity.

3. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?

• A. Level of consciousness
• B. Deep tendon reflexes
• C. Blood pressure
• D. Urinary output

Correct answer: C

Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.

4. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
• B. A client who gave birth 3 days ago and reports breast fullness
• C. A client who gave birth 12 hours ago and reports an increase in urinary output
• D. A client who gave birth 8 hours ago and is saturating a perineal pad every hour

Correct answer: D

Rationale: The nurse should see the client saturating a perineal pad every hour first. This client may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention. The other options describe clients with less urgent needs. The client needing Rho(D) immune globulin can wait, the breast fullness in the client who gave birth 3 days ago can be addressed after managing the postpartum hemorrhage, and an increase in urinary output in a client who gave birth 12 hours ago is not indicative of an immediate emergency like postpartum hemorrhage.

5. A nurse is providing teaching to a client who has chronic kidney failure and an AV fistula for hemodialysis with a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching?

• A. Reduces blood pressure
• B. Inhibits clotting of fistula
• C. Promotes RBC production
• D. Stimulates growth of neutrophils

Correct answer: C

Rationale: The correct answer is C: Promotes RBC production. Epoetin alfa stimulates red blood cell production, which is important for clients with chronic kidney disease who may have anemia due to decreased erythropoietin production by the kidneys. Options A, B, and D are incorrect: epoetin alfa does not directly reduce blood pressure, inhibit clotting of the fistula, or stimulate growth of neutrophils.

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