Nursing Elites

1. To ensure client safety before starting blood transfusions, the following are needed before the procedure can be done EXCEPT:

• A. take baseline vital signs
• B. warm the blood to room temperature for 30 minutes before administering the transfusion
• C. have two nurses verify client identification, blood type, unit number, and expiration date of blood
• D. get consent signed for blood transfusion

Correct answer: D

Rationale: To ensure client safety before starting blood transfusions, taking baseline vital signs, warming the blood to room temperature, and having two nurses verify client identification, blood type, unit number, and expiration date of blood are crucial steps. Consent for blood transfusion is required but is typically obtained before the procedure. The focus before the procedure should be on confirming the right client, blood product, and ensuring the blood is prepared correctly to minimize risks of transfusion reactions.

2. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

3. The correct temperature to store vaccines in a refrigerator is:

• A. between -4 deg C and +8 deg C
• B. between 2 deg C and +8 deg C
• C. between -8 deg C and 0 deg C
• D. between -8 deg C and +4 deg C

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. Which of the following nursing interventions is appropriate after a total thyroidectomy?

• A. Place pillows under your patient’s shoulders.
• B. Raise the knee-gatch to 30 degrees
• C. Keep you patient in a high-fowler’s position.
• D. Support the patient’s head and neck with pillows and sandbags.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

5. A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?

• A. Fiber
• B. Vitamin A
• C. Vitamin C
• D. Oxalates

Correct answer: C

Rationale: Vitamin C aids in the absorption of iron by enhancing the body's ability to absorb non-heme iron, which is found in plant-based foods. This vitamin helps convert iron into a form that is more easily absorbed in the intestines. Choices A, B, and D are incorrect because fiber, Vitamin A, and oxalates can actually inhibit the absorption of iron. Fiber can bind to iron and reduce its absorption, Vitamin A does not directly enhance iron absorption, and oxalates found in some foods like spinach and rhubarb can also hinder iron absorption.

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