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. What information should the nurse include in the client's health record after a fall in the bathroom?

• A. Client fell while trying to go to the bathroom
• B. The UAP left the client alone and a fall occurred
• C. The client was found on the floor with no pulse
• D. The client fell, sustaining a fracture to the left hip

Correct answer: D

Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.

3. A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Assess the client's lung sounds.
• D. Reposition the client to relieve dyspnea.

Correct answer: A

Rationale: In a client with chronic heart failure experiencing worsening dyspnea, the priority action for the nurse is to administer oxygen at 2 liters per nasal cannula. This helps improve oxygenation and alleviate respiratory distress. Administering a diuretic (Choice B) may be necessary but addressing oxygenation comes first. While assessing lung sounds (Choice C) is important, it is not the immediate priority when the client is in respiratory distress. Repositioning the client (Choice D) may help with comfort but does not address the underlying issue of inadequate oxygenation.

4. A client is scheduled for surgery in the morning and is NPO. Which statement indicates that the client understands the reason for being NPO?

• A. Being NPO helps reduce the risk of nausea.
• B. I should not eat or drink anything to prevent complications during surgery.
• C. NPO reduces the risk of aspiration during surgery.
• D. NPO helps ensure the stomach is empty during surgery.

Correct answer: C

Rationale: The correct answer is C: 'NPO reduces the risk of aspiration during surgery.' When a client is NPO (nothing by mouth) before surgery, it is to prevent aspiration, which can lead to serious complications such as pneumonia. Choice A is incorrect because being NPO is more about preventing aspiration than nausea. Choice B is a general statement without specifying the reason for being NPO. Choice D is partially correct but does not emphasize the crucial aspect of preventing aspiration, which is the primary reason for fasting before surgery.

5. The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?

• A. 100 ml/hour
• B. 75 ml/hour
• C. 60 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct infusion rate, convert 300 mcg/hour to mg/hour (300 mcg = 0.3 mg). Since the IV solution is 1 mg in 250 ml, the rate is calculated as 0.3 mg/hour = 75 ml/hour. Therefore, the nurse should set the pump to 75 ml/hour. Choice A (100 ml/hour) is incorrect as it does not reflect the accurate calculation. Choice C (60 ml/hour) is incorrect as it is lower than the correct rate. Choice D (125 ml/hour) is incorrect as it is higher than the correct rate.

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