Nursing Elites

1. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?

• A. Obtain the pre-transfusion hemoglobin level.
• B. Prime the tubing and set up the blood pump.
• C. Monitor vital signs every 15 minutes for the first hour.
• D. Ensure the accuracy of the blood type match.

Correct answer: D

Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.

2. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

• A. Complete a fall-risk assessment.
• B. Educate the client and family about fall risks.
• C. Eliminate safety hazards from the client’s environment.
• D. Ensure the client uses assistive aids in their possession.

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

3. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

• A. HR 105/min
• B. BMI 25 kg/m²
• C. BP 148/92
• D. Glucose 45 mg/dL

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

4. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?

• A. Use gloves to inspect the hair.
• B. Apply a lindane-based shampoo immediately.
• C. Shave the patient's hair off.
• D. Ignore the movement and continue.

Correct answer: A

Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.

5. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

• A. Administer pain medication 45 minutes before changing the client’s dressing.
• B. Change the dressing less frequently.
• C. Apply a topical anesthetic before removing the dressing.
• D. Use a non-adherent dressing to reduce pain.

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

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