Nursing Elites

1. A healthcare professional is preparing to administer packed red blood cells (PRBCs) to a client. Which of the following actions should the healthcare professional take?

• A. Infuse the PRBCs over 8 hours.
• B. Verify the client's blood type and Rh factor.
• C. Administer the PRBCs through a 24-gauge catheter.
• D. Administer the PRBCs with lactated Ringer's solution.

Correct answer: B

Rationale: Verifying the client's blood type and Rh factor is crucial before administering blood products to ensure compatibility and prevent adverse reactions. Option A is incorrect because PRBCs are typically infused over a specific time frame based on hospital policy and client condition, not necessarily over 8 hours. Option C is incorrect as PRBCs are usually administered through a larger gauge catheter to prevent hemolysis. Option D is incorrect because PRBCs are typically administered with normal saline and not lactated Ringer's solution.

2. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?

• A. Administer calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the infusion.
• D. Keep the client on NPO status.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

3. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?

• A. Feed the infant glucose water every 2 hours.
• B. Ensure the newborn wears a diaper.
• C. Keep the infant's head covered with a cap.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.

4. Which of the following lab values indicates a patient on warfarin is at a therapeutic level?

• A. INR of 1.1
• B. PT of 12 seconds
• C. INR of 2.5
• D. Platelet count of 150,000

Correct answer: C

Rationale: An INR of 2.5 indicates a therapeutic level for a patient on warfarin. The INR (International Normalized Ratio) is the most accurate way to monitor and adjust warfarin doses. An INR of 1.1 (Choice A) is below the therapeutic range, indicating a need for an increased dose. PT (Prothrombin Time) of 12 seconds (Choice B) is not specific for warfarin therapy monitoring. Platelet count (Choice D) is not directly related to monitoring warfarin therapy.

5. A client taking haloperidol is exhibiting extrapyramidal symptoms. Which intervention should the nurse anticipate?

• A. Increase the dose of haloperidol.
• B. Administer benztropine.
• C. Administer naloxone.
• D. Monitor blood pressure before administering the next dose.

Correct answer: B

Rationale: The correct intervention for a client exhibiting extrapyramidal symptoms while taking haloperidol is to administer benztropine. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal symptoms caused by antipsychotic medications like haloperidol. Increasing the dose of haloperidol (Choice A) would exacerbate the symptoms rather than alleviate them. Administering naloxone (Choice C) is not indicated for extrapyramidal symptoms. Monitoring blood pressure (Choice D) is important but not the primary intervention for managing extrapyramidal symptoms.

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