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. Each of the following is a form of vitamin K, except one. Which is the exception?

• A. Phylloquinone
• B. Tocopherol
• C. Menaquinone
• D. Menadione

Correct answer: B

Rationale: Tocopherol, Choice B, is not a form of vitamin K; it is another name for vitamin E. Phylloquinone (Choice A), menaquinone (Choice C), and menadione (Choice D) are all forms of vitamin K. Phylloquinone is vitamin K1 found in green plants, menaquinone is vitamin K2 produced in the large intestine and found in animal tissues, and menadione is a synthetic form of vitamin K. Therefore, Choice B is the correct answer because it does not belong to the vitamin K group, unlike the other options.

3. This vaccine content is derived from RNA recombinants.

• A. Measles C. Hepatitis B vaccines
• B. Tetanus toxoids D. DPT
• C.
• D.

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.

4. If it is determined that a child is being physically abused by a parent, what would be the most important goal for the nurse to establish with the family?

• A. The child and any siblings will reside in a secure environment
• B. The family will feel at ease in their relationship with the counselor
• C. The family will gain insight into their abusive behavior patterns
• D. The mother will learn to apply verbal discipline with her children

Correct answer: A

Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.

5. A client who is 2 days postoperative following abdominal surgery is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

• A. Cranberry juice
• B. Flavored gelatin
• C. Skim milk
• D. Chicken broth

Correct answer: A

Rationale: Cranberry juice is an appropriate choice for a client transitioning from a clear liquid diet to full liquids post abdominal surgery. It provides hydration and some essential nutrients. Flavored gelatin is usually allowed on a clear liquid diet and may not be suitable for a full liquids phase. Skim milk and chicken broth are typically introduced in a later stage of the diet progression, closer to a soft diet, due to their higher protein and fat content.

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