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. 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. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

4. The RR nurse should monitor for the most common postoperative complication of:

• A. hemorrhage
• B. endotracheal tube perforation
• C. osopharyngeal edema
• D. epiglottis

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. A community health nurse is conducting a class on what to expect during pregnancy. What instruction should the nurse include on weight gain?

• A. Failure to obtain the required weight gain during pregnancy will increase the risk of preterm birth.
• B. An obese client should not gain as much weight as a client with a normal body mass index.
• C. A client with a normal body mass index should plan on gaining 50 pounds.
• D. Clients do not need to eat for two when they are pregnant.

Correct answer: A

Rationale: Adequate weight gain during pregnancy is essential as failure to obtain the required weight gain can increase the risk of preterm birth. Choice B is incorrect because it is important for obese clients to gain an appropriate amount of weight during pregnancy, not the same as those with a normal body mass index. Choice C is incorrect as gaining 50 pounds for a client with a normal body mass index is excessive. Choice D is incorrect as the common saying 'eating for two' during pregnancy is a misconception; pregnant individuals do not need to double their caloric intake.

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