Nursing Elites

1. A client scheduled for a CT scan of the head with contrast is being taught by a nurse. Which of the following statements by the client indicates a need for further teaching?

• A. I will not eat or drink for 4 hours before the procedure
• B. I will keep my head still throughout the procedure
• C. I will experience a warm sensation when the dye is injected
• D. I can take my morning dose of metformin

Correct answer: D

Rationale: The correct answer is D because metformin should be held before a contrast CT scan to prevent the risk of kidney damage. Choices A, B, and C are all correct statements regarding the preparation and experience of a CT scan with contrast. It is important to fast before the procedure, keep the head still during the scan, and expect a warm sensation when the dye is injected.

2. What are the priority nursing assessments for a patient who has just undergone major surgery?

• A. Providing analgesia as prescribed
• B. Monitoring for signs of infection
• C. Assessing the surgical site for bleeding
• D. Monitoring the patient's vital signs

Correct answer: B

Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.

3. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

• A. Monitor the client's intake and output every 6 hours
• B. Administer furosemide to the client
• C. Check the client's IV infusion every 8 hours
• D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours

Correct answer: D

Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.

4. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his parents' room. Which of the following actions should the nurse take?

• A. Check the newborn's identification bracelet against the chart
• B. Obtain permission from the newborn's parents
• C. Respectfully deny the grandparent's request
• D. Review the newborn's footprints record

Correct answer: C

Rationale: In this scenario, where the grandparent lacks proper identification, the nurse should respectfully deny the request to take the newborn. It is crucial to prioritize the newborn's safety and security by following hospital policies and procedures. Checking the newborn's identification bracelet against the chart (Choice A) may not be sufficient to address the situation at hand, as the grandparent's lack of identification is the primary concern. While obtaining permission from the newborn's parents (Choice B) is important, the lack of proper identification from the grandparent takes precedence. Reviewing the newborn's footprints record (Choice D) is not necessary in this situation, as the immediate concern is ensuring proper identification and security before allowing the newborn to leave the nursery.

5. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?

• A. Administer acetaminophen
• B. Stop the transfusion
• C. Slow the transfusion rate
• D. Administer antihistamines

Correct answer: B

Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.

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