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. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse.
• B. Encourage the client to get to the toilet.
• C. In a loud voice, call for help.
• D. Gently lower the client to the floor.

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

3. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

4. An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:

• A. Changes in sleep patterns
• B. Changes in eating patterns with weight loss
• C. Excessive fatigue and increased concern with bodily functions
• D. Hyperorality

Correct answer: D

Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.

5. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

• A. Complete blood count (CBC)
• B. Serum potassium level
• C. Liver function tests (LFTs)
• D. Serum cholesterol level

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.

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