Nursing Elites

1. During a client's first hospitalization, which of the following actions ensures the safety of the client?

• A. Keep unnecessary furniture out of the way
• B. Keep the lights on at all times
• C. Keep side rails up at all times
• D. Keep all equipment out of view

Correct answer: A

Rationale: During a client's first hospitalization, it is essential to keep unnecessary furniture out of the way to prevent obstacles and ensure a safe environment. This action helps reduce the risk of accidents or falls, promoting the client's safety and well-being. Keeping the lights on at all times may not be necessary and can disrupt the client's rest. Keeping side rails up at all times can restrict the client's movement and independence unnecessarily. Keeping all equipment out of view may hinder the healthcare team's ability to monitor and access necessary tools for providing care.

2. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?

• A. Take quick breaths upon inhalation.
• B. Place your hand over your stomach.
• C. Take a deep breath in through your nose.
• D. Puff your cheeks upon exhalation.

Correct answer: C

Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.

3. 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.

4. When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?

• A. Air should be instilled into the monitoring system after the procedure.
• B. The client should be positioned on the left side after the procedure.
• C. The transducer should be level with the second intercostal space after the line is placed.
• D. A chest x-ray is needed to verify placement after the procedure.

Correct answer: D

Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.

5. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?

• A. Client who has dysphagia
• B. Client who has AIDS
• C. Client who was vaccinated for pneumococcus and influenza 6 months ago
• D. Client who has a closed head injury and is receiving ventilation

Correct answer: C

Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.

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