Nursing Elites

1. The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?

• A. Administer pre-transfusion medication
• B. Ensure the client has an adequate fluid intake
• C. Monitor the client's vital signs
• D. Verify the blood type with another nurse

Correct answer: D

Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.

2. A client with cirrhosis develops ascites. What is the nurse’s priority intervention?

• A. Administer diuretics as prescribed.
• B. Restrict fluid intake to manage fluid overload.
• C. Position the client in Fowler’s position and assess for respiratory distress.
• D. Measure the client's abdominal girth daily.

Correct answer: B

Rationale: The correct answer is B: Restrict fluid intake to manage fluid overload. In a client with cirrhosis developing ascites, the priority intervention is to restrict fluid intake. This helps manage fluid overload, prevent further complications, such as respiratory distress or kidney impairment, and reduce the accumulation of ascitic fluid. Administering diuretics may be a part of the treatment plan, but the primary focus should be on fluid restriction. Positioning the client in Fowler’s position and measuring the abdominal girth are important interventions but not the priority when managing ascites in cirrhosis.

3. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

• A. Focus on reality orientation to place and person
• B. Assist with the report of the client's complaint to the police
• C. Obtain more details of the client's claim of abuse
• D. Document the statement in the client's chart with a report to the manager

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

4. A client with deep vein thrombosis (DVT) is prescribed heparin. What lab value should the nurse monitor to assess the effectiveness of the therapy?

• A. Prothrombin time (PT).
• B. Partial thromboplastin time (PTT).
• C. International Normalized Ratio (INR).
• D. Hemoglobin and hematocrit.

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is the lab value used to monitor the effectiveness of heparin therapy in clients with DVT. It measures the intrinsic pathway of coagulation and is prolonged by heparin therapy. Prothrombin time (PT) and International Normalized Ratio (INR) are primarily used to monitor warfarin therapy, not heparin. Checking hemoglobin and hematocrit levels is important but does not directly assess the effectiveness of heparin therapy in DVT.

5. The nurse is assessing a client with rheumatoid arthritis who is taking a nonsteroidal anti-inflammatory drug (NSAID). Which laboratory value should the nurse monitor?

• A. Potassium
• B. Hemoglobin
• C. Serum creatinine
• D. White blood cell count

Correct answer: C

Rationale: When a client with rheumatoid arthritis is taking NSAIDs, the nurse should monitor serum creatinine levels. NSAIDs can potentially cause kidney damage, so monitoring creatinine levels helps assess for renal impairment. While monitoring hemoglobin, potassium, and white blood cell count may also be relevant in some cases, serum creatinine is the priority due to the risk of renal complications associated with NSAID use.

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