Nursing Elites

1. What is the nurse's priority action when a client receiving a unit of packed red blood cells experiences tingling in the fingers and headache?

• A. Call the health care provider (HCP).
• B. Stop the transfusion.
• C. Slow the infusion rate.
• D. Assess the intravenous (IV) site for infiltration.

Correct answer: B

Rationale: When a client receiving a packed red blood cell transfusion experiences tingling in the fingers and headache, these symptoms may indicate an adverse reaction to the transfusion. The nurse's priority action is to immediately stop the transfusion and initiate a normal saline infusion at a keep vein open (KVO) rate. This helps maintain the client's vein patency while addressing the adverse reactions. After stopping the transfusion and initiating the saline infusion, the nurse should assess the client, including vital signs evaluation. Subsequently, the healthcare provider should be notified. Calling the healthcare provider is important, but it should be done after the immediate action of stopping the transfusion. Slowing the infusion rate is not appropriate during a suspected transfusion reaction as it can exacerbate the adverse effects. Assessing the IV site for infiltration is a routine nursing intervention and is not the priority when managing a potential adverse reaction to a blood transfusion.

2. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

3. A client is being treated for anxiety and desires to be free from anxious feelings and despair. According to Maslow's hierarchy of needs, which level does this client need to meet?

• A. Physiological
• B. Safety
• C. Belonging
• D. Self-esteem

Correct answer: B

Rationale: According to Maslow's hierarchy of needs, safety needs come right after physiological needs. Safety needs include feelings of security and stability. When a client is treated for anxiety and seeks to be free from anxious feelings and despair, they are primarily aiming to meet their safety needs. By addressing anxiety and moving towards a sense of safety, the client can progress to addressing higher-level needs. Choices A, C, and D are incorrect in this scenario. Physiological needs (Choice A) refer to basic needs like food, water, and shelter. Belonging (Choice C) and self-esteem (Choice D) are higher-level needs in Maslow's hierarchy that come after safety needs. Therefore, the most appropriate level for the client in this case is safety.

4. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

5. Which signs and symptoms would the nurse observe in a client with schizophrenia?

• A. Traumatic flashbacks and hypervigilance
• B. Depression and psychomotor retardation
• C. Loosened associations and hallucinations
• D. Ritualistic behavior and obsessive thinking

Correct answer: C

Rationale: In clients with schizophrenia, the nurse would observe loosened associations and hallucinations. Loosened associations refer to disorganized thinking where thoughts are not logically connected. Hallucinations involve perceiving things that are not based in reality. Traumatic flashbacks and hypervigilance are more indicative of post-traumatic stress disorder. Depression and psychomotor retardation are common in depression, not schizophrenia. Ritualistic behavior and obsessive thinking are typically seen in obsessive-compulsive disorders, not schizophrenia.

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