Nursing Elites

1. A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the professional take to identify the client?

• A. Match the client's blood type with the type and cross-match specimens
• B. Confirm the provider's prescription matches the number on the blood component
• C. Ask the client to state their blood type and the date of their last blood donation
• D. Ensure that the client's identification band matches the number on the blood unit

Correct answer: Match the client's blood type with the type and cross-match specimens

Rationale: When preparing to administer an autologous blood product, it is crucial to correctly identify the client to prevent errors. Matching the client's blood type with the type and cross-match specimens ensures that the blood product is intended for the correct recipient. This step helps in verifying the patient's identity and avoiding any transfusion-related complications. Confirming the blood type through type and cross-matching is a standard practice to ensure patient safety during blood transfusions.

2. A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?

• A. There are portable oxygen delivery systems that you can take with you.
• B. When you go out, you can remove the oxygen and then reapply it when you get home.
• C. You probably will not be able to go out as much as you used to.
• D. Home health services will come to see you so you will not need to get out.

Correct answer: There are portable oxygen delivery systems that you can take with you.

Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.

3. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

• A. Prime IV tubing with 0.9% sodium chloride
• B. Use a 24-gauge IV catheter
• C. Obtain filterless IV tubing
• D. Place blood in the warmer for 1 hr

Correct answer: A: Prime IV tubing with 0.9% sodium chloride

Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.

4. A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?

• A. A client who has a BMI of 30
• B. A female client who is postmenopausal
• C. A client who has a fractured femur
• D. A client who has chronic atrial fibrillation

Correct answer: A female client who is postmenopausal

Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.

5. A 38-year-old patient’s vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?

• A. Respiratory rate only
• B. Temperature only
• C. Pulse rate and temperature
• D. Temperature and respiratory rate

Correct answer: D

Rationale: Both an elevated temperature and an increased respiratory rate are abnormal vital signs that could indicate an underlying health issue. Reporting both of these findings is crucial to ensure appropriate evaluation and intervention if needed.

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