Nursing Elites

1. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

• A. Obtain informed consent from the client for the PRBC transfusion
• B. Review the client’s medical history for a history of transfusion reactions
• C. Assess the client’s baseline vital signs before starting the transfusion
• D. Verify the blood type and crossmatch with another licensed nurse

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

2. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

• A. Encourage increased fluid intake.
• B. Place the client in a high Fowler's position.
• C. Measure the client's intake and output.
• D. Restrict dietary sodium intake.

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

3. After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?

• A. Complete an incident report.
• B. Select another sterile needle.
• C. Disinfect the needle with an alcohol swab.
• D. Notify the supervisor immediately.

Correct answer: B

Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.

4. The nurse is providing discharge teaching to a client with a new diagnosis of osteoporosis. Which instruction should the nurse include?

• A. Increase dietary intake of calcium-rich foods.
• B. Avoid activities that increase the risk of falls.
• C. Avoid prolonged exposure to sunlight.
• D. Increase intake of vitamin D supplements.

Correct answer: B

Rationale: Avoiding activities that increase the risk of falls (B) is the most crucial instruction for a client with osteoporosis to prevent fractures. Osteoporosis weakens bones, making them more susceptible to fractures from falls. While increasing calcium intake (A) is important for bone health, avoiding falls takes precedence to prevent immediate harm. Avoiding prolonged exposure to sunlight (C) is not directly related to osteoporosis management. Increasing vitamin D supplements (D) is beneficial for bone health, but fall prevention is more critical in this scenario.

5. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?

• A. Sensory pattern, area, intensity, and nature of the pain.
• B. Identification of trigger points through palpation and manual pressure on painful areas.
• C. Current schedule and total dosages of medications used for breakthrough pain.
• D. Assessment of sympathetic responses indicative of acute pain onset.

Correct answer: A

Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.

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