Nursing Elites

1. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

• A. Oliguria and jaundice
• B. Urticaria and wheezing
• C. Headache, chills, & fever
• D. Hypertension and flushing

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

• A. Bottled water is an appropriate choice to increase fluid intake.
• B. The salad bar is a healthy choice when dining out.
• C. Soft-boiled eggs are an appropriate source of protein.
• D. Eating at a buffet is a good choice to increase caloric intake.

Correct answer: A

Rationale: In neutropenia, which is a low count of neutrophils, the client is at a high risk of infection. It is crucial to emphasize the importance of proper hydration to maintain overall health. Bottled water is a safe choice as it reduces the risk of exposure to contaminants that could further compromise the client's immune system. The other options, like the salad bar, soft-boiled eggs, and eating at a buffet, may not be suitable for a client with neutropenia due to the risk of bacterial contamination or exposure to pathogens that could lead to infections, which should be avoided.

3. A nurse is assessing the nutritional status of an infant who is 6 months old. The infant weighed 2.7 kg at birth. Which of the following indicates to the nurse that the infant is within the expected range?

• A. 5.5 kg
• B. 6.4 kg
• C. 4.5 kg
• D. 3.6 kg

Correct answer: B

Rationale: The correct answer is B, 6.4 kg. An infant's weight should approximately double by 6 months. In this case, starting from a birth weight of 2.7 kg, a weight of 6.4 kg at 6 months indicates normal growth. Choice A (5.5 kg) is below the expected range for a 6-month-old infant. Choices C (4.5 kg) and D (3.6 kg) are also below the expected weight gain, indicating inadequate growth.

4. Instruction on health promotion regarding urinary elimination is important. Which would you include?

• A. Hold urine as long as possible before emptying the bladder to strengthen the sphincter muscles
• B. If a burning sensation is experienced while voiding, drink water
• C. After urination, wipe from the anal area towards the pubis
• D. Tell the client to empty the bladder at each voiding

Correct answer: D

Rationale: The correct answer is to instruct the client to empty the bladder at each voiding. This is essential to prevent urinary retention and reduce the risk of urinary tract infections. Choice A is incorrect because holding urine for prolonged periods can lead to urinary retention and increase the risk of infections. Choice B is incorrect as pineapple juice can exacerbate a burning sensation due to its acidity; the correct approach is to drink water to dilute the urine. Choice C is incorrect as wiping from the anal area towards the pubis can introduce bacteria into the urinary tract, potentially causing infections.

5. The nurse is correct in performing suctioning when she applies the suction intermittently during:

• A. Insertion of the suction catheter
• B. Withdrawing of the suction catheter
• C. both insertion and withdrawing of the suction catheter
• D. When the suction catheter tip reaches the bifurcation of the trachea

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

Similar Questions