Nursing Elites

1. In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention should focus on:

• A. Slow the infusion, Call the physician and assess the patient
• B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the physician
• C. Stop the infusion, Call the physician and assess the client
• D. Slow the confusion and keep a patent IV line open for administration of medication

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. The nurse is caring for a client taking warfarin. Which meal brought in by the client's family is a priority to remove before the client eats it?

• A. Oriental cabbage salad with chicken
• B. Beef enchilada, rice, and beans
• C. Ham and cheese sandwich
• D. Macaroni salad and grapefruit slices

Correct answer: C

Rationale: The correct answer is C. Ham is high in vitamin K, which can interfere with warfarin. Vitamin K can decrease the effectiveness of warfarin, an anticoagulant medication. Choices A, B, and D do not contain high levels of vitamin K and are less likely to interfere with the client's warfarin therapy.

3. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

4. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might just become worse while relating with other drug users. The mother’s behavior can be described as:

• A. Unhelpful
• B. Codependent
• C. Caretaking
• D. Supportive

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

5. What type of gastrointestinal complication is most likely to be caused by the use of antibiotics to treat H. pylori infection?

• A. Hemoptysis
• B. Altered taste sensation
• C. Flatulence
• D. Bloody stools

Correct answer: B

Rationale: The correct answer is B, Altered taste sensation. The use of antibiotics is known to cause changes in taste sensation as a side effect, especially when used to treat H. pylori infections. Hemoptysis (Choice A) refers to coughing up blood, and while it can be a symptom of various conditions, it is not typically associated with the use of antibiotics. Flatulence (Choice C) and bloody stools (Choice D) can also occur as gastrointestinal complications, but they are not the most likely side effect when treating H. pylori with antibiotics. Therefore, choices A, C, and D are incorrect.

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