Nursing Elites

1. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

2. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?

• A. Continuity of patient care promotes efficient and cost-effective nursing care.
• B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
• C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
• D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.

3. A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

• A. Non-rebreather mask
• B. Venturi mask
• C. Nasal cannula
• D. Simple face mask

Correct answer: B

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

4. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

• A. Ineffective airway clearance related to thick, tenacious secretions.
• B. Ineffective airway clearance related to dry, hacking cough.
• C. Ineffective individual coping with COPD.
• D. Pain related to immobilization of affected leg.

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

5. A healthcare professional in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the professional not expect?

• A. Bradycardia
• B. Cyanosis
• C. Hypotension
• D. Dyspnea

Correct answer: A

Rationale: Bradycardia is not typically associated with a flail chest. Flail chest is characterized by paradoxical chest wall movement, respiratory distress, and hypoxia, but it does not usually cause bradycardia. The other options, such as cyanosis (bluish discoloration of the skin due to poor oxygenation), hypotension (low blood pressure), and dyspnea (difficulty breathing), are commonly seen in patients with flail chest due to the underlying respiratory compromise.

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