Nursing Elites

1. What is the most important step when preparing to administer a blood transfusion?

• A. Check if the client has a fever
• B. Ensure the blood type is compatible with the client
• C. Administer the blood via IV push
• D. Ensure the blood is warmed to body temperature

Correct answer: B

Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.

2. Which nursing action is a priority when managing a client with a wound infection?

• A. Change the wound dressing every 24 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial when managing a client with a wound infection. This step helps identify the specific pathogens causing the infection, allowing for the prescription of the most effective antibiotics. Changing the wound dressing every 24 hours (Choice A) is important for wound care but not the priority when an infection is present. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and may delay wound healing. Applying a wet-to-dry dressing (Choice D) is not recommended for infected wounds as it can cause trauma to the wound bed during dressing changes.

3. Which intervention is most important for a client with rheumatoid arthritis?

• A. Massage inflamed joints with creams and oils
• B. Provide support to flexed joints with pillows and pads
• C. Position the client on their abdomen several times a day
• D. Assist with heat application and range of motion exercises

Correct answer: D

Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.

4. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

• A. Document the client's status every 60 minutes.
• B. Provide a staff member to stay with the client continuously.
• C. Measure vital signs every 4 hours.
• D. Obtain a prescription for the restraints every 8 hours.

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

5. A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Poor appetite
• C. Irritability
• D. Decreased urination

Correct answer: C

Rationale: Irritability in infants can indicate worsening dehydration, which needs to be reported. Weight gain (Choice A) would be a positive finding, indicating adequate fluid intake. Poor appetite (Choice B) is common with diarrhea but not as concerning as irritability. Decreased urination (Choice D) can also be a sign of dehydration, but irritability is more specific to worsening dehydration in this case.

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