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. 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.

3. Which outcome has been shown to be most closely associated with breastfeeding infants of mothers who smoke?

• A. poor temperature regulation
• B. vision impairment
• C. vomiting
• D. elevated blood pressure

Correct answer: C

Rationale: The correct answer is C: vomiting. Infants breastfed by mothers who smoke are more likely to experience vomiting and gastrointestinal issues due to the transfer of nicotine and other harmful substances through breast milk. Choices A, B, and D are incorrect. Poor temperature regulation, vision impairment, and elevated blood pressure are not the primary outcomes closely associated with breastfeeding infants of mothers who smoke.

4. What is the recommended dietary intervention for a patient with hyperlipidemia?

• A. Increase saturated fat intake
• B. Reduce fiber intake
• C. Increase dietary fiber intake
• D. Reduce protein intake

Correct answer: C

Rationale: Increasing dietary fiber can help reduce cholesterol levels in patients with hyperlipidemia.

5. During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?

• A. Discuss nutritional requirements with the client.
• B. Refer the client to a senior citizen center.
• C. Arrange for a home-delivered meal program.
• D. Perform a nutrition screening.

Correct answer: D

Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.

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