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 heart failure is prescribed spironolactone. What is the nurse's priority intervention?

• A. Monitor the client's potassium levels closely.
• B. Assess for signs of hyperkalemia.
• C. Instruct the client to increase intake of potassium-rich foods.
• D. Increase the client’s fluid intake to prevent dehydration.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia (high potassium levels). Therefore, the nurse's priority intervention should be to assess the client for signs of hyperkalemia, such as muscle weakness, fatigue, and potentially dangerous cardiac arrhythmias. Monitoring potassium levels closely (choice A) is important but assessing for signs of hyperkalemia takes precedence. Instructing the client to increase intake of potassium-rich foods (choice C) can exacerbate hyperkalemia in this case. Increasing the client’s fluid intake to prevent dehydration (choice D) is not directly related to the potential side effect of spironolactone.

3. A client with tuberculosis (TB) is being discharged on isoniazid and rifampin. What instruction should the nurse prioritize?

• A. Complete the full course of antibiotics.
• B. Notify the healthcare provider if you experience tingling in your fingers.
• C. Use a disposable mask when in contact with others.
• D. Monitor liver function tests monthly.

Correct answer: C

Rationale: The correct answer is to instruct the client to use a disposable mask when in contact with others. TB is highly contagious, and wearing a mask can help prevent the spread of the disease to others. Choice A is important but not the priority as using a mask directly impacts public health. Choice B is related to a potential side effect of isoniazid, peripheral neuropathy, but immediate healthcare provider notification is not required. Choice D is relevant due to the potential hepatotoxicity of isoniazid and rifampin, but it is not the priority instruction in this scenario.

4. A pregnant client complains of heartburn. What instruction should the nurse provide?

• A. Eat spicy food to help digestion.
• B. Eat small meals throughout the day to avoid a full stomach.
• C. Drink carbonated beverages to ease digestion.
• D. Avoid drinking fluids after meals.

Correct answer: B

Rationale: The correct instruction for a pregnant client experiencing heartburn is to eat small meals throughout the day to avoid a full stomach. This helps prevent the stomach from becoming overly full, reducing the likelihood of heartburn during pregnancy. Choices A, C, and D are incorrect. Eating spicy food can exacerbate heartburn, carbonated beverages may trigger heartburn due to gas, and avoiding fluids after meals does not directly address the issue of heartburn.

5. A client with hypertension is prescribed a thiazide diuretic. What dietary recommendation should the nurse make?

• A. Encourage a diet low in carbohydrates and fats.
• B. Avoid foods high in vitamin K, such as spinach and kale.
• C. Increase salt intake to prevent dehydration.
• D. Eat potassium-rich foods like bananas and oranges.

Correct answer: D

Rationale: The correct answer is D: 'Eat potassium-rich foods like bananas and oranges.' Thiazide diuretics can lead to potassium loss, so it is essential for clients to consume potassium-rich foods to maintain adequate levels. Choice A is incorrect because focusing solely on low carbohydrates and fats does not address the specific issue of potassium loss. Choice B is unrelated as vitamin K content is not a concern with thiazide diuretics. Choice C is incorrect as increasing salt intake would exacerbate hypertension and not prevent dehydration.

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