Nursing Elites

1. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?

• A. Bleeding time
• B. Hemoglobin and hematocrit
• C. White blood cells
• D. Platelets

Correct answer: B

Rationale: Corrected Hemoglobin and hematocrit levels should be monitored closely after blood transfusions to assess the effectiveness and identify any complications. Monitoring hemoglobin and hematocrit levels helps evaluate the patient's oxygen-carrying capacity and blood volume. While platelets are crucial for clotting, they are not typically affected immediately after a blood transfusion. White blood cell count monitoring is more relevant in assessing infection or immune response, not directly related to a blood transfusion. Bleeding time measures platelet function, which is not the primary concern immediately after a blood transfusion.

2. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

• A. Institute seizure precautions
• B. Monitor neurologic status every hour
• C. Place in respiratory/secretion precautions
• D. Cefotaxime IV 50 mg/kg/day divided q6h

Correct answer: C

Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.

3. A nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?

• A. Tomato juice
• B. Tea
• C. Milk
• D. Dried beans

Correct answer: A

Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.

4. A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?

• A. Boiled rice
• B. Italian bread
• C. Broiled salmon filet
• D. Pickled beets

Correct answer: D

Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.

5. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula

• A. Every four to six hours
• B. Continuously
• C. In a bolus
• D. Every hour

Correct answer: B

Rationale: When administering enteral feeding through a jejunostomy tube, the nurse should administer the formula continuously. Continuous feeding is essential for optimal nutrient absorption and to prevent complications. Administering the formula every four to six hours, in a bolus, or every hour may lead to inadequate nutrition, improper absorption, and an increased risk of complications such as aspiration or dumping syndrome, making these choices incorrect.

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