Nursing Elites

1. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.

2. A client underwent coronary artery bypass grafting and is learning about following a low-cholesterol diet. Which of the following food choices indicates the client's understanding of these dietary instructions?

• A. Liver
• B. Milk
• C. Beans
• D. Eggs

Correct answer: C

Rationale: The correct answer is C: Beans. Beans are an excellent choice for individuals following a low-cholesterol diet post-coronary artery bypass grafting due to their low cholesterol content. Beans are high in fiber and protein, making them a heart-healthy option. Choice A, Liver, is high in cholesterol and should be avoided in a low-cholesterol diet. Choice B, Milk, contains cholesterol and saturated fats, which are not ideal for this diet. Choice D, Eggs, are also high in cholesterol and should be limited in a low-cholesterol diet.

3. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?

• A. Check the protein level in urine
• B. Have the client turn to the left side
• C. Take the temperature
• D. Monitor the urine output

Correct answer: B

Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.

4. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

5. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

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