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. Mang Carlos has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

• A. Give extraordinary measures to save Mang Carlos
• B. Stay with Mang Carlos and Do nothing
• C. Call the physician
• D. Activate Code Blue

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.

3. Which type of drug is most likely to cause unintentional weight gain?

• A. Antiemetics
• B. Sedatives
• C. Corticosteroids
• D. Antibiotics

Correct answer: C

Rationale: Corticosteroids are most likely to cause unintentional weight gain. They influence the metabolism and fat distribution in the body, leading to weight gain. On the other hand, antiemetics are drugs that are used to prevent nausea and vomiting, and they do not typically cause weight gain. Sedatives, while they can cause drowsiness and may lead to less physical activity, are not directly associated with weight gain. Lastly, antibiotics are used to fight bacteria and while they can cause temporary digestive issues, they do not typically result in long-term weight gain.

4. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

5. Which substance would most likely need to be restricted in patients with heart failure who use diuretics to help reduce fluid retention?

• A. potassium
• B. magnesium
• C. sodium
• D. chloride

Correct answer: C

Rationale: Sodium restriction is crucial in heart failure management to prevent fluid retention, which can worsen symptoms of heart failure.

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