Nursing Elites

1. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

2. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

• A. Carrots
• B. White bread
• C. Bananas
• D. Apples

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

3. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Stroke secondary to hemorrhage
• B. Myocardial infarction
• C. Heart failure
• D. Renal failure

Correct answer: A

Rationale: Stroke is a major complication of uncontrolled hypertension. Elevated BP, especially at levels like 158/106, can cause damage to blood vessels in the brain, leading to a hemorrhagic stroke. Controlling BP is essential to prevent such life-threatening events. Myocardial infarction (choice B) is more commonly associated with coronary artery disease, while heart failure (choice C) and renal failure (choice D) can be complications of uncontrolled hypertension but are not directly related to the elevated BP leading to a hemorrhagic stroke.

4. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

• A. Nausea and vomiting
• B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
• C. Diffuse macular rash
• D. Muscle tenderness

Correct answer: B

Rationale: A fever of 103 degrees Fahrenheit indicates that the infection is not under control despite antibiotic therapy. Fever is a common sign of ongoing infection or inadequate response to treatment. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically indicative of the effectiveness of antibiotic therapy in treating infective endocarditis.

5. The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?

• A. Flush the tube with water every 4 hours
• B. Check the tube placement before each feeding
• C. Secure the tube to the client's nose with tape
• D. Keep the head of the bed elevated at 30 degrees

Correct answer: B

Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.

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