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 diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor closely?

• A. Monitor for elevated blood pressure.
• B. Monitor for ketonuria.
• C. Monitor for peripheral edema.
• D. Monitor for hypokalemia.

Correct answer: D

Rationale: The correct answer is to monitor for hypokalemia. In diabetes insipidus, excessive urination can lead to electrolyte imbalances, particularly low potassium levels (hypokalemia). The loss of potassium through increased urination can result in muscle weakness, cardiac dysrhythmias, and other serious complications. Elevated blood pressure (Choice A) is not a typical complication of diabetes insipidus due to pituitary tumors. Ketonuria (Choice B) is more commonly associated with diabetes mellitus due to inadequate insulin levels. Peripheral edema (Choice C) is not a direct complication of diabetes insipidus.

3. The nurse reviews the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client support the diagnosis of tuberculosis?

• A. Mucopurulent cough and night sweats
• B. Fatigue and headache
• C. Persistent cough and weight gain
• D. Weight loss and fever

Correct answer: A

Rationale: A mucopurulent cough and night sweats are hallmark signs of active tuberculosis. These symptoms are key indicators of TB as the combination of a productive cough with night sweats is highly suggestive of the disease. Fatigue and headache (choice B) are nonspecific symptoms that can occur in many conditions and are not specific to TB. Persistent cough and weight gain (choice C) are not typical findings in tuberculosis. Weight loss and fever (choice D) can be present in TB, but the specific combination of mucopurulent cough and night sweats is more specific to the diagnosis.

4. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?

• A. Provide a detailed handout with complex terms
• B. Use simple language and visual aids
• C. Encourage the client to research the diagnosis online
• D. Incorporate medical jargon to explain the condition

Correct answer: B

Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.

5. The nurse is assessing a client with rheumatoid arthritis who is taking a nonsteroidal anti-inflammatory drug (NSAID). Which laboratory value should the nurse monitor?

• A. Potassium
• B. Hemoglobin
• C. Serum creatinine
• D. White blood cell count

Correct answer: C

Rationale: When a client with rheumatoid arthritis is taking NSAIDs, the nurse should monitor serum creatinine levels. NSAIDs can potentially cause kidney damage, so monitoring creatinine levels helps assess for renal impairment. While monitoring hemoglobin, potassium, and white blood cell count may also be relevant in some cases, serum creatinine is the priority due to the risk of renal complications associated with NSAID use.

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