Nursing Elites

1. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?

• A. Check the client’s blood type compatibility
• B. Monitor the client for signs of transfusion reaction
• C. Verify the correct client and blood product with another healthcare professional
• D. All of the above

Correct answer: D

Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.

2. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

• A. Assess the client's hemoglobin levels to determine if the client is in shock
• B. Call the surgeon and prepare to take the client back to the operating room
• C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
• D. No action is required as postoperative bleeding can be expected

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

3. Which membrane lines the abdominal cavity?

• A. Perineum
• B. Pericardium
• C. Pleura
• D. Peritoneum

Correct answer: D

Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.

4. The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?

• A. Peripheral edema
• B. Jugular vein distention
• C. Shortness of breath
• D. Weight gain

Correct answer: C

Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.

5. A client undergoing chemotherapy reports a sudden onset of severe back pain. What should the nurse do first?

• A. Administer pain medication as prescribed
• B. Assess the pain's nature and intensity
• C. Encourage the client to rest and apply a hot pack
• D. Notify the physician immediately

Correct answer: B

Rationale: The correct first action for the nurse is to assess the nature and intensity of the pain. This initial assessment is crucial in determining the underlying cause of the pain, whether it is related to the chemotherapy or another issue. Understanding the pain's characteristics will guide the nurse in implementing appropriate interventions and seeking timely medical assistance if needed. Administering pain medication without a thorough assessment may mask important symptoms and delay necessary treatment. Encouraging rest and hot pack application may be appropriate interventions but should come after assessing the pain. Notifying the physician immediately can be important but should follow the initial assessment to provide comprehensive information to the healthcare provider.

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