Nursing Elites

1. Which nursing action is essential when administering a blood transfusion?

• A. Ensure the blood is administered within 4 hours.
• B. Check the patient's vital signs every 30 minutes during the transfusion.
• C. Administer the transfusion at a slow rate for the first 15 minutes.
• D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

2. Which action should the nurse take to minimize the risk of medication errors?

• A. Prepare medications ahead of time to ensure they are ready.
• B. Ensure two nurses double-check medications before administration.
• C. Administer medications at the same time each day.
• D. Rely on memory to administer the correct medications.

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

3. A client is prescribed 1g of potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g in 250 ml of dextrose 5%. What rate should the nurse set the IV pump to run at?

• A. 40 ml/hr
• B. 42 ml/hr
• C. 44 ml/hr
• D. 46 ml/hr

Correct answer: B

Rationale: To calculate the IV rate, divide the total volume by the total time in hours. In this case, 1 g in 250 ml is to be infused over 6 hours. Therefore, 250 ml / 6 hr = 42 ml/hr. This means the IV pump should be set to run at 42 ml/hr. Choices A, C, and D are incorrect as they do not accurately calculate the infusion rate based on the provided information.

4. A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medications should the nurse include under Schedule II?

• A. Buprenorphine hydrochloride
• B. Hydrocodone bitartrate
• C. Diazepam
• D. Morphine

Correct answer: B

Rationale: The correct answer is B: Hydrocodone bitartrate. According to the Controlled Substances Act, hydrocodone bitartrate is classified as a Schedule II controlled substance due to its high potential for abuse and addiction. Diazepam (Choice C) and morphine (Choice D) are classified as Schedule IV and Schedule II controlled substances, respectively. Buprenorphine hydrochloride (Choice A) is classified as a Schedule III controlled substance. Therefore, hydrocodone bitartrate should be included under Schedule II medications when discussing the categories regulated under the Controlled Substances Act.

5. A client is experiencing chest pain. Which action should the nurse take first?

• A. Administer aspirin
• B. Provide oxygen
• C. Perform an ECG
• D. Administer nitroglycerin

Correct answer: D

Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.

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