Nursing Elites

1. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?

• A. Continue to measure the client’s vital signs every thirty minutes until the transfusion is complete
• B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
• C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
• D. Notify the nurse when the transfusion has finished, so further client assessment can be done

Correct answer: A

Rationale: The correct instruction for the UAP is to continue measuring the client’s vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.

2. While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?

• A. Cardiopulmonary resuscitation with uterine tilt
• B. The Heimlich maneuver using chest thrusts
• C. The Heimlich maneuver using subdiaphragmatic thrusts
• D. Call 911 immediately then begin cardiopulmonary resuscitation

Correct answer: C

Rationale: The correct action for the nurse to take when a pregnant woman is choking and unable to speak is to perform the Heimlich maneuver using subdiaphragmatic thrusts. This technique is recommended for a pregnant woman to prevent harm to the fetus. Option A, cardiopulmonary resuscitation with uterine tilt, is not indicated for a choking episode. Option B, the Heimlich maneuver using chest thrusts, can potentially harm the gravid uterus. Option D, calling 911 immediately before providing assistance, can lead to a delay in addressing the immediate choking emergency.

3. In Duchenne muscular dystrophy, if a child has a Gower sign, what behavior should the nurse expect the child to exhibit?

• A. Stands from sitting on the floor by using hands to walk up legs
• B. Exhibits muscular atrophy of upper and lower extremities
• C. Is unable to stand because of contractures of both hips
• D. Walks with an unsteady gait and slaps feet on the floor

Correct answer: A

Rationale: The Gower sign is a characteristic finding in Duchenne muscular dystrophy where a child uses hands to walk up the legs when standing from a sitting position due to proximal muscle weakness. This behavior is indicative of the child trying to compensate for weak hip and thigh muscles. Choices B, C, and D are incorrect because they do not describe the specific behavior associated with the Gower sign. Muscular atrophy, contractures of both hips, and an unsteady gait with foot slapping are not directly related to the Gower sign.

4. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

• A. Usual and current weight
• B. Color and amount of urine
• C. Number and frequency of stools
• D. Intake and output 24 hours prior to admission

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

5. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

• A. Anxiety related to treatment plan
• B. Deficient knowledge of lifestyle changes
• C. Ineffective coping related to denial
• D. Decisional conflict due to stress

Correct answer: C

Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.

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