Nursing Elites

1. During a blood transfusion, which sign or symptom should prompt the healthcare provider to immediately stop the transfusion?

• A. Slight increase in blood pressure
• B. Elevated temperature and chills
• C. Mild nausea
• D. Slight headache

Correct answer: B

Rationale: The correct answer is B: Elevated temperature and chills. These symptoms are indicative of a transfusion reaction, which can be severe and life-threatening. It is crucial to stop the transfusion immediately and notify the healthcare provider for further assessment and management. Elevated temperature and chills are classic signs of a transfusion reaction, specifically indicating a possible febrile non-hemolytic reaction. Choice A, a slight increase in blood pressure, is not typically a reason to stop a transfusion unless it is a significant sudden increase. Mild nausea (Choice C) and a slight headache (Choice D) are common side effects of blood transfusions and are not primary indicators of a transfusion reaction that require immediate cessation of the transfusion.

2. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?

• A. Apply an ice pack to the incision site.
• B. Monitor the client's temperature.
• C. Document the findings and continue to monitor.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.

3. Which of the following is a priority for the nurse to include in the teaching of a client who was recently prescribed alprazolam (Xanax) as an oral medication?

• A. Monitor heart rate before taking the medication
• B. Monitor temperature daily
• C. Avoid unprotected exposure to sunlight
• D. Avoid alcohol

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol.' Alprazolam (Xanax) can have central nervous system depressant effects, which are exacerbated by alcohol. It is crucial to avoid alcohol while taking this medication to prevent severe sedation and respiratory depression. Monitoring heart rate (choice A) is not directly related to alprazolam administration. Monitoring temperature daily (choice B) is not a priority teaching point for a client prescribed alprazolam. Avoiding unprotected exposure to sunlight (choice C) is not specifically linked to the use of alprazolam.

4. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

5. What intervention should the PN implement when taking the rectal temperature of an adult client?

• A. Lubricate the tip of the thermometer with a water-based gel.
• B. Gently insert the thermometer 1 inch into the rectum.
• C. Hold the thermometer in place the entire time while taking the temperature.
• D. Place the client in the left lateral position.

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

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