Nursing Elites

1. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

• A. Ensure the injection produces a wheal on the skin
• B. Administer the injection in the client's thigh
• C. Use an intradermal needle for the injection
• D. Avoid touching the site after injection

Correct answer: A

Rationale: The correct answer is A: Ensure the injection produces a wheal on the skin. A wheal indicates that the PPD has been administered correctly, allowing for the proper interpretation of results. Administering the injection in the client's thigh (choice B) is not the recommended site for PPD administration; it should be administered intradermally. Using an 18-gauge needle (choice C) is unnecessary and not the standard practice for PPD administration as a smaller gauge needle is preferred for intradermal injections. Massaging the site after injection (choice D) can lead to inaccurate results by dispersing the solution, so it is important to avoid touching the site after the injection to prevent altering the test results.

2. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?

• A. Medication history
• B. Fluid and electrolyte imbalances
• C. Psychosocial stressors
• D. Environmental factors

Correct answer: B

Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.

3. A client with acute diverticulitis is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the instructions?

• A. I will avoid eating fiber until this condition resolves
• B. I will take a laxative daily
• C. I will receive the nutrients I need through my IV fluids
• D. I will eat only solid foods

Correct answer: A

Rationale: The correct answer is A. During acute diverticulitis, avoiding fiber is essential as it helps reduce irritation of the intestines. Choice B is incorrect because taking a laxative daily can exacerbate diverticulitis. Choice C is incorrect as IV fluids mainly provide hydration and electrolytes, not all essential nutrients. Choice D is incorrect because during acute diverticulitis, a low-fiber or liquid diet is typically recommended to rest the bowel.

4. What is the first step in preparing a blood transfusion?

• A. Administer the blood via IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Administer diuretics to prevent fluid overload

Correct answer: B

Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.

5. A healthcare professional is preparing to administer a blood transfusion. What is the healthcare professional's first action?

• A. Check the client's temperature
• B. Verify that the client's blood type matches the blood product
• C. Administer the blood through an IV push
• D. Ensure the blood is warmed before administration

Correct answer: B

Rationale: The healthcare professional's first action before administering a blood transfusion should be to verify that the client's blood type matches the blood product. This step is crucial to ensure compatibility and prevent potentially severe transfusion reactions. Checking the client's temperature (Choice A) is important but not the first action in this scenario. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are typically administered as a slow infusion. Ensuring the blood is warmed before administration (Choice D) is not the first action and is not a standard practice in blood transfusions.

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