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 chronic obstructive pulmonary disease (COPD) presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. What is the nurse's first action?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Notify the healthcare provider immediately.
• C. Position the client in high Fowler's position.
• D. Suction the client's airway.

Correct answer: A

Rationale: Administering oxygen at 2 L/min via nasal cannula is the nurse's first action when a client with COPD presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. Oxygen therapy helps improve oxygen saturation in patients with COPD and respiratory distress. While notifying the healthcare provider is important, immediate intervention to improve oxygenation takes priority. Positioning the client in high Fowler's position can also assist with breathing but is not the initial action in this scenario. Suctioning the airway is not indicated unless there are secretions obstructing the airway, which is not mentioned in the scenario.

3. A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?

• A. Encourage bed rest to prevent strain on the hip
• B. Assist the client with early ambulation
• C. Provide continuous passive motion therapy
• D. Administer pain medication before activity

Correct answer: B

Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.

4. A client with multiple sclerosis is receiving intravenous methylprednisolone. What is the nurse's priority action?

• A. Monitor blood glucose levels every 6 hours.
• B. Monitor for signs of infection.
• C. Encourage increased oral fluid intake.
• D. Check the client's temperature every 4 hours.

Correct answer: B

Rationale: When a client with multiple sclerosis is receiving intravenous methylprednisolone, the nurse's priority action is to monitor for signs of infection. Corticosteroids like methylprednisolone can suppress the immune system, increasing the risk of infection. Monitoring for signs of infection allows for early detection and prompt intervention. Monitoring blood glucose levels may be important in clients receiving corticosteroids for prolonged periods, but it is not the priority in this case. Encouraging increased oral fluid intake is generally beneficial but not the priority over monitoring for infection. Checking the client's temperature is important but not the priority action compared to monitoring for signs of infection.

5. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?

• A. Report orange-colored urine as a sign of kidney dysfunction.
• B. Expect red-orange discoloration of urine as a harmless side effect.
• C. Monitor for signs of liver toxicity.
• D. Call the healthcare provider if vision changes occur.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.

Similar Questions