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. What symptoms would most likely be associated with a transient ischemic attack?

• A. confusion and difficulty speaking
• B. headache and blurred vision
• C. chest pain and pressure
• D. claudication and peripheral edema

Correct answer: A

Rationale: The correct answer is A: confusion and difficulty speaking. These symptoms are commonly associated with a transient ischemic attack (TIA), which is a temporary blockage of blood flow to the brain. Choice B, headache and blurred vision, are more indicative of other conditions such as migraines or eye problems. Choice C, chest pain and pressure, are more characteristic of cardiac issues like a heart attack. Choice D, claudication and peripheral edema, are typical of peripheral arterial disease and not typically seen in TIAs.

3. A client with pre-dialysis end-stage kidney disease is being taught about diet. Which of the following instructions should the nurse include?

• A. Increase intake of dietary phosphorus.
• B. Eliminate foods high in protein from your diet.
• C. Reduce intake of foods high in potassium.
• D. Increase intake of sodium-containing foods.

Correct answer: C

Rationale: In pre-dialysis end-stage kidney disease, reducing intake of foods high in potassium is crucial as impaired kidney function can lead to potassium buildup in the blood, which can be dangerous. High potassium levels can cause irregular heartbeats and even cardiac arrest. Therefore, advising the client to reduce potassium-rich foods is essential to prevent complications. Choices A, B, and D are incorrect. Increasing dietary phosphorus, eliminating foods high in protein, or increasing sodium-containing foods are not appropriate recommendations for a client with pre-dialysis end-stage kidney disease as they can exacerbate the condition.

4. The nurse is working with a patient who recently had a stroke. The patient frequently chokes and coughs when eating and is having difficulty feeding herself. What is the best way to ensure adequate nutrition?

• A. to have an aide feed her at each meal
• B. to ask a family member to assist during meals
• C. to provide tube feedings for the patient
• D. to initiate TPN for the patient

Correct answer: C

Rationale: The best way to ensure adequate nutrition for a stroke patient who frequently chokes and coughs when eating and has difficulty feeding herself is to provide tube feedings. Tube feedings are a safe and effective method to deliver nutrition directly to the stomach or intestines, bypassing the swallowing mechanism, reducing the risk of aspiration. Having an aide feed her each meal (choice A) may not address the underlying issue of swallowing difficulty and aspiration risk. Asking a family member to be present at each meal (choice B) does not provide a definitive solution to the patient's nutritional needs. Placing the patient on total parenteral nutrition (TPN) (choice D) is a more invasive and typically reserved for patients who cannot tolerate enteral feedings or have non-functional gastrointestinal tracts.

5. Which is NOT a classification of carbohydrate?

• A. Monosaccharides
• B. Disaccharides
• C. Polysaccharides
• D. Triglycerides

Correct answer: D

Rationale: The correct answer is D, Triglycerides. Triglycerides are a type of fat, not a carbohydrate. Monosaccharides, disaccharides, and polysaccharides are all classifications of carbohydrates based on the number of sugar units they contain. Monosaccharides are the simplest form with one sugar unit, disaccharides contain two sugar units, and polysaccharides have multiple sugar units linked together.

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