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 discussing sources of vitamin K with a client. Which food should the nurse recommend?

• A. Fish
• B. Leafy greens
• C. Citrus fruits
• D. Nuts

Correct answer: B

Rationale: Leafy greens are rich in vitamin K, which is important for blood clotting.

3. What is considered fast breathing in a 13-month-old child if the respiratory rate (RR) exceeds which value?

• A. 40 breaths per minute
• B. 50 breaths per minute
• C. 60 breaths per minute
• D. 30 breaths per minute

Correct answer: C

Rationale: In the context of pediatric care, a respiratory rate of more than 60 breaths per minute in a child aged 13 months is considered fast breathing, hence option 'C' is correct. Options 'A', 'B', and 'D' are incorrect as they do not meet the specified criteria for fast breathing in a 13-month-old. Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, including monitoring respiratory rates, to ensure that interventions are appropriately targeted and outcomes are optimized.

4. The home health nurse visits older adult clients at an assisted living center. Which foods should the nurse recommend to correct the main nutrient deficits for this population?

• A. Carbohydrates
• B. Oily fish and krill oil
• C. Yellow vegetables
• D. Dairy products

Correct answer: D

Rationale: The correct answer is D: Dairy products. Older adults are often deficient in calcium and vitamin D, which are abundant in dairy products. These nutrients are essential for maintaining bone health. Choice A (Carbohydrates) is incorrect because while carbohydrates are an essential nutrient, they are not specifically addressing the main nutrient deficits for older adults. Choice B (Oily fish and krill oil) is incorrect as these foods are sources of omega-3 fatty acids and not specifically addressing the main nutrient deficits common in older adults. Choice C (Yellow vegetables) is incorrect because although vegetables are important for overall health, they do not directly address the main nutrient deficits typically seen in older adults.

5. The nurse is assessing a client with a new diagnosis of Listeria food poisoning. What action should the nurse take first?

• A. Educate the client on safe food practices.
• B. Start a traceback to identify the source of the outbreak.
• C. Report the case to the county board of health.
• D. Ask the client if they have consumed any unpasteurized products.

Correct answer: D

Rationale: The correct first action for the nurse to take when assessing a client with a new diagnosis of Listeria food poisoning is to inquire if the client has consumed any unpasteurized products. This is crucial because Listeria contamination is often associated with unpasteurized dairy products and undercooked meats. Educating the client on safe food practices (Choice A) is important but not the priority at this initial assessment stage. Starting a traceback to identify the source of the outbreak (Choice B) and reporting the case to the county board of health (Choice C) are necessary actions but should come after gathering information directly from the client regarding potential exposure to high-risk foods.

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