Nursing Elites

1. A client receiving a blood transfusion develops a fever. What action should the nurse take?

• A. Stop the transfusion immediately.
• B. Administer an antihistamine as prescribed.
• C. Administer a diuretic as prescribed.
• D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

2. A client with a nasogastric tube receiving intermittent enteral feedings should be positioned in which way?

• A. Flush the tube with 15 mL of sterile water before feedings.
• B. Place the client in a supine position during feedings.
• C. Position the client with the head of the bed elevated 45 degrees.
• D. Check gastric residuals every 8 hours.

Correct answer: C

Rationale: Positioning the client with the head of the bed elevated at 45 degrees is crucial during enteral feedings to prevent aspiration. This position helps reduce the risk of regurgitation and aspiration of feedings into the lungs. Option A is not necessary before feedings. Placing the client in a supine position (Option B) increases the risk of aspiration. Checking gastric residuals every 8 hours (Option D) is important but not directly related to positioning during enteral feedings.

3. A client who is at 10 weeks of gestation is being taught about nutrition during pregnancy. Which statement by the client indicates an understanding of the teaching?

• A. I should consume 1,200 calories per day.
• B. I should increase my daily intake of folic acid.
• C. I should drink 2 liters of water each day.
• D. I should limit my intake of iron-rich foods.

Correct answer: B

Rationale: The correct answer is B. Increasing folic acid intake is crucial during pregnancy to prevent neural tube defects. Option A is incorrect because calorie requirements during pregnancy vary and are generally higher than 1,200 calories per day. Option C is not specific to pregnancy nutrition teaching, although hydration is important. Option D is incorrect as iron-rich foods are typically recommended during pregnancy to prevent anemia.

4. A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should avoid eating foods high in potassium.
• B. I will check my blood pressure at least once a week.
• C. I should increase my intake of dairy products.
• D. I should exercise for 30 minutes at least 5 days a week.

Correct answer: D

Rationale: The correct answer is D. Exercising for 30 minutes at least 5 days a week helps manage hypertension by promoting cardiovascular health. Statements A, B, and C are incorrect. Avoiding foods high in potassium is not necessary unless specifically advised by a healthcare provider. Checking blood pressure once a week is not frequent enough for effective monitoring. Increasing dairy product intake is not a recommended approach to managing hypertension.

5. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid crowded places to reduce my risk of infection.
• B. I will take this medication on an empty stomach.
• C. I will stop taking this medication if I experience nausea.
• D. I will take this medication for 2 weeks and then stop.

Correct answer: A

Rationale: The correct answer is A: 'I will avoid crowded places to reduce my risk of infection.' When taking prednisone, clients should avoid crowded places to reduce the risk of infection due to its immunosuppressive effects. Choice B is incorrect because prednisone is usually taken with food to reduce stomach upset. Choice C is incorrect because clients should not stop taking prednisone abruptly, even if they experience nausea. Choice D is incorrect because prednisone should be tapered off gradually under healthcare provider guidance instead of being stopped abruptly after 2 weeks.

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