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 nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?

• A. Sliced bananas
• B. Raw celery
• C. Peanut butter
• D. Marshmallows

Correct answer: A

Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.

3. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication:

• A. Can predispose to dysrhythmias
• B. May lead to oliguria
• C. May cause irritability and anxiety
• D. Sometimes alters consciousness

Correct answer: A

Rationale: The correct answer is A: Hypokalemia increases the risk of dysrhythmias when taking digoxin, making potassium intake crucial. Digoxin toxicity is more likely in patients with low potassium levels, leading to an increased risk of dysrhythmias. Choices B, C, and D are incorrect because hypokalemia in combination with digoxin is primarily associated with dysrhythmias rather than oliguria, irritability, anxiety, or alteration of consciousness.

4. A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 episodes of incontinent diarrhea
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.

5. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain a sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw the catheter in a circular motion

Correct answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

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