Nursing Elites

1. A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take first?

• A. Check the client's identification bracelet.
• B. Obtain the client's vital signs.
• C. Initiate the transfusion slowly over the first 15 minutes.
• D. Verify the client's blood type and Rh factor.

Correct answer: D

Rationale: The correct answer is to verify the client's blood type and Rh factor first before administering blood. This is crucial to ensure compatibility and prevent transfusion reactions. Checking the client's identification bracelet (Choice A) is important but should come after verifying blood type. Obtaining vital signs (Choice B) and initiating the transfusion slowly (Choice C) are important steps but verifying blood type is the priority to ensure safe blood administration.

2. A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Bowel sounds present in all four quadrants
• B. Temperature of 37.5°C (99.5°F)
• C. Scant urine output
• D. Serosanguineous wound drainage

Correct answer: D

Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.

3. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

• A. Place the client upright on a donut-shaped cushion.
• B. Teach the client to shift his weight every 15 minutes while sitting.
• C. Turn and reposition the client every 3 hours.
• D. Assess pressure points every 24 hours.

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

4. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

5. How should pain be assessed in a non-verbal patient?

• A. Observe facial expressions
• B. Use the Wong-Baker faces scale
• C. Assess heart rate
• D. Ask the patient to rate their pain

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

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