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 preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?

• A. Administer the medication over 15 minutes.
• B. Monitor the client's urine output every 8 hours.
• C. Check the client's creatinine level before administering the medication.
• D. Assess the client for a history of allergies to antibiotics.

Correct answer: C

Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.

3. A nurse is caring for a client who has cirrhosis. Which of the following laboratory values should the nurse expect to be decreased?

• A. Bilirubin.
• B. Albumin.
• C. Ammonia.
• D. Prothrombin time.

Correct answer: B

Rationale: In clients with cirrhosis, albumin levels are typically decreased due to impaired liver function. Bilirubin levels are often increased in cirrhosis due to the liver's inability to process bilirubin efficiently. Ammonia levels may be elevated in cirrhosis due to impaired ammonia metabolism by the liver. Prothrombin time is usually prolonged in cirrhosis because the liver's ability to synthesize clotting factors is impaired.

4. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?

• A. Sodium 144 mEq/L
• B. Potassium 5.2 mEq/L
• C. Bicarbonate 24 mEq/L
• D. Magnesium 1.9 mEq/L

Correct answer: B

Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.

5. A healthcare provider is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the healthcare provider to delegate?

• A. Adjusting the flow rate of the client's oxygen tank.
• B. Collecting a urine sample.
• C. Measuring the client's pain level.
• D. Transporting a client to x-ray.

Correct answer: D

Rationale: The correct answer is 'D: Transporting a client to x-ray.' This task is appropriate for delegation to assistive personnel as it involves transferring the client safely from one location to another, which does not require the specialized skills of a healthcare provider. Adjusting the flow rate of the client's oxygen tank (Choice A) involves making clinical decisions that should be done by a licensed healthcare provider. Collecting a urine sample (Choice B) and measuring the client's pain level (Choice C) require critical thinking and assessment skills that are typically within the scope of practice of licensed healthcare providers, not assistive personnel.

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