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. The nurse is caring for a client with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

• A. Administer morphine for pain relief.
• B. Encourage the client to perform isometric exercises.
• C. Position the client flat in bed.
• D. Restrict fluid intake.

Correct answer: A

Rationale: Administering morphine is a priority intervention during the acute phase of myocardial infarction (MI). Morphine not only provides pain relief but also reduces myocardial oxygen demand, which is crucial in this situation. Choice B is incorrect because isometric exercises can increase myocardial oxygen demand and are not recommended during the acute phase of MI. Choice C is incorrect as elevating the head of the bed, not keeping the client flat, is preferred to reduce workload on the heart. Choice D is incorrect because fluid intake should be encouraged unless contraindicated, as adequate hydration is essential for cardiac function.

3. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake.
• B. Engage in regular physical activity.
• C. Avoid foods high in fat.
• D. Limit fluid intake to 1 liter per day.

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

4. What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag only when necessary
• B. Eat a low-residue diet
• C. Assess the stoma for color and swelling
• D. Irrigate the colostomy only if advised by a healthcare provider

Correct answer: C

Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.

5. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed
• B. Perform chest physiotherapy
• C. Encourage increased fluid intake
• D. Provide humidified oxygen

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

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