Nursing Elites

1. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

• A. Stay with the client for the first 15 minutes of blood administration
• B. Stay with the client for the entire period of blood administration
• C. Run the infusion at a faster rate during the first 15 minutes
• D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

2. All of the following are instructions for proper foot care to be given to a client with peripheral vascular disease caused by diabetes. Which one is not?

• A. Trim nails using a nail clipper
• B. Apply cornstarch to the foot
• C. Always check the temperature of the water before bathing
• D. Use canvas shoes

Correct answer: A

Rationale: The correct answer is 'A', which says trim nails using a nail clipper. This is incorrect because patients with peripheral vascular disease, particularly those caused by diabetes, should not trim their nails themselves due to the risk of injury, infection, and poor wound healing. The other options, 'B', 'C', and 'D', are correct advice for diabetic foot care. Applying cornstarch can help keep the feet dry and prevent fungal infections. Checking the water temperature before bathing can prevent burns, as patients with peripheral vascular disease often have decreased sensation in their feet. Wearing canvas shoes can improve foot ventilation and reduce the risk of foot ulcers and infections.

3. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

4. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer.

• A. Barium enema
• B. Carcinoembryonic antigen
• C. Annual digital rectal examination
• D. Proctosigmoidoscopy

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

5. Nurse Joel and Ana are helping a 16-year-old Nursing Student in a case filed against the student for frustrated homicide. Nurse Joel and Ana are aware of the different circumstances of crimes. They are correct in identifying which of the following circumstances will be best applied in this case?

• A. Justifying
• B. Aggravating
• C. Mitigating
• D. Exempting

Correct answer: A

Rationale: In cases of frustrated homicide, the circumstance of 'justifying' is the most applicable. Justifying circumstances are those that exempt the individual from criminal liability because the act is considered morally right or justified under the circumstances. Aggravating circumstances would worsen the offense, mitigating circumstances would lessen the penalty, and exempting circumstances would completely excuse the individual from liability, none of which are suitable in a case of frustrated homicide.

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