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 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.

3. A client is diagnosed with chronic renal failure, and the nurse is teaching dietary modifications. What should be limited in this client's diet?

• A. Carbohydrates
• B. Fats
• C. Proteins
• D. Vitamins

Correct answer: C

Rationale: In chronic renal failure, proteins should be limited in the diet. When the kidneys are not functioning well, the buildup of protein byproducts can put additional stress on them. Limiting protein intake can help reduce the burden on the kidneys. Carbohydrates and fats do not need to be restricted in the same way as proteins. Vitamins are essential nutrients that should not be limited in the diet unless specified by a healthcare provider for a specific reason.

4. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

• A. Difference in the intake and output
• B. Changes in the mucous membranes
• C. Skin turgor
• D. Weekly weight

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

5. A client with adrenal crisis has a temperature of 102°F, heart rate of 138 bpm, and blood pressure of 80/60 mmHg. Which action should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In a client with adrenal crisis presenting with a high temperature, tachycardia, and hypotension, the priority action for the nurse to implement first is to infuse an intravenous fluid bolus. This intervention aims to address the hypotension by increasing the circulating volume and improving perfusion. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering an oral antipyretic (Choice C) may help reduce the fever but does not address the primary issue of hypotension. Covering the client with a cooling blanket (Choice D) may help with temperature control but does not address the hemodynamic instability caused by the adrenal crisis.

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