Nursing Elites

1. While taking the history of an older adult client, which assessment finding alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

• A. "I am often cold and need to wear a sweater."?
• B. "I seem to urinate more when I drink coffee."?
• C. "In the summer, I feel thirsty more often."?
• D. "My rings seem to be tighter this week."?

Correct answer: D

Rationale: The correct answer is 'My rings seem to be tighter this week.' This assessment finding indicates possible fluid retention, which can be a sign of fluid or electrolyte imbalance in an older adult. Choices A, B, and C do not specifically point towards fluid or electrolyte imbalance. Feeling cold, increased urination with coffee consumption, and feeling thirsty in the summer are not direct indicators of fluid or electrolyte imbalance in this context.

2. The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?

• A. Administer prescribed diphenhydramine (Benadryl).
• B. Continue to monitor the client's vital signs.
• C. Stop the infusion of packed red blood cells.
• D. Slow the infusion rate of the transfusion

Correct answer: D

Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.

3. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

4. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

• A. Asks the client to both say and spell their full name before starting the blood transfusion
• B. Ensures that another qualified healthcare professional checks the unit before administering
• C. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
• D. Ensures that all staff wear appropriate personal protective equipment during the transfusion process

Correct answer: C

Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.

5. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

• A. Call the healthcare provider and report the finding.
• B. Reassess the client’s blood pressure at the next follow-up appointment.
• C. Administer an additional antihypertensive medication to the client.
• D. Teach the client lifestyle modifications to decrease blood pressure.

Correct answer: D

Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.

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