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. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best?

• A. Fish sticks, french fries, banana, cookies, milk
• B. Ground beef patty, lima beans, wheat roll, raisins, milk
• C. Chicken nuggets, macaroni, peas, cantaloupe, milk
• D. Peanut butter and jelly sandwich, apple slices, milk

Correct answer: B

Rationale: The correct answer is B. Ground beef, lima beans, and raisins are rich sources of iron, making this meal plan the most suitable for a child with anemia. Ground beef is a high-iron meat, while lima beans and raisins are also excellent sources of iron. Fish sticks, french fries, banana, and cookies in option A lack sufficient iron content compared to the options in B. Chicken nuggets, macaroni, and peas in option C are not as iron-rich as the ground beef, lima beans, and raisins in option B. Peanut butter and jelly sandwich with apple slices in option D also fall short in providing enough iron when compared to the iron-rich components of option B.

3. When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is in the

• A. Arms.
• B. Upper torso.
• C. Head.
• D. Feet.

Correct answer: B

Rationale: The correct answer is 'Upper torso.' In elderly individuals, the center of gravity tends to shift upwards towards the upper torso due to various factors such as changes in posture and muscle strength. Understanding this is crucial for safe ambulation as it helps in maintaining balance and stability. Choices A, 'Arms,' C, 'Head,' and D, 'Feet,' are incorrect. The center of gravity is not typically located in the arms, head, or feet. It is higher up in the body, specifically in the upper torso. Knowing the correct location of the center of gravity is essential for assisting elderly clients in ambulation effectively and preventing falls.

4. When admitting a client, what information should the nurse record in the client’s record first?

• A. Assessment of the client
• B. Client’s medical history
• C. Plan of care
• D. Vital signs

Correct answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

5. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

• A. Bag bath
• B. Sponge bath
• C. Partial bed bath
• D. Complete bed bath

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

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