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. Pain medications given to the burn clients are best given via what route?

• A. IV C. Oral
• B. IM D. SQ
• C.
• D.

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

4. High blood pressure is defined as systolic and diastolic measurements greater than or equal to:

• A. 140 mm Hg and 90 mm Hg, respectively
• B. 150 mm Hg and 80 mm Hg, respectively
• C. 160 mm Hg and 110 mm Hg, respectively
• D. 180 mm Hg and 120 mm Hg, respectively

Correct answer: A

Rationale: High blood pressure, or hypertension, is typically defined as having a systolic pressure of 140 mm Hg or higher and/or a diastolic pressure of 90 mm Hg or higher. Therefore, the correct answer is A. Choice B is incorrect because it suggests a higher systolic measurement than the standard definition. Choice C is incorrect as it provides an even higher systolic measurement and a much higher diastolic measurement. Choice D is also incorrect as it suggests extremely elevated blood pressure values, well above the typical definition of hypertension.

5. Which of the following treatments is not recommended for a child classified with no dehydration?

• A. Administering 1,000 ml to 1,400 ml within 4 hours
• B. Continuing feeding
• C. Allowing the child to take as much fluid as he wants
• D. Returning the child to the doctor if the condition worsens

Correct answer: B

Rationale: The correct answer is B. Continuing feeding is a recommended treatment for a child classified with no dehydration. This helps maintain the child's nutritional status and supports recovery. Options A, C, and D are appropriate interventions for a child with no dehydration. Option A ensures adequate fluid intake, option C promotes hydration, and option D ensures appropriate follow-up if the condition worsens.

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