Nursing Elites

1. A nurse is caring for a client who is receiving packed RBCs. Which of the following actions should the nurse take?

• A. Monitor the client's blood glucose level every hour
• B. Administer the blood using a microdrip set
• C. Assess the client's vital signs every 2 hours
• D. Infuse the blood within 4 hours

Correct answer: D

Rationale: The correct answer is to infuse the blood within 4 hours. This is crucial to prevent bacterial contamination and hemolysis during blood transfusions. Monitoring the client's blood glucose level every hour (Choice A) is not directly related to packed RBC transfusions. Administering the blood using a microdrip set (Choice B) may be appropriate for specific medications but is not a requirement for packed RBC transfusions. Assessing the client's vital signs every 2 hours (Choice C) is important for monitoring the client's overall condition but is not as time-sensitive as ensuring the timely infusion of packed RBCs.

2. A nurse is caring for a client who has pneumonia and is receiving oxygen therapy. Which of the following findings indicates the need for suctioning?

• A. Increased respiratory rate.
• B. Oxygen saturation 96%.
• C. Clear lung sounds.
• D. Productive cough.

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate. An increased respiratory rate suggests the client is having difficulty clearing secretions and may require suctioning. Oxygen saturation of 96% is within the normal range and indicates adequate oxygenation. Clear lung sounds suggest good air entry without the need for suctioning. A productive cough, although a symptom of pneumonia, does not directly indicate the need for suctioning.

3. A nurse is providing discharge teaching to a client who has had a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

• A. I will avoid sitting in a chair for longer than 30 minutes.
• B. I will avoid crossing my legs when sitting.
• C. I will bend at the hips to pick up items from the floor.
• D. I will avoid using a raised toilet seat.

Correct answer: C

Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.

4. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in the microwave prior to administration

Correct answer: A

Rationale: The correct answer is to administer the feeding over 30 minutes. This slow administration helps prevent complications like nausea. Placing the child in a supine position after the feeding can increase the risk of aspiration, making choice B incorrect. Changing the feeding bag and tubing every 3 days is important for infection control and hygiene but is not directly related to the administration process, making choice C incorrect. Warming the formula in the microwave is not recommended as it can create hot spots that may burn the child's mouth or esophagus, so choice D is incorrect.

5. A nurse is caring for a client who has a new prescription for metformin. Which of the following findings in the client's medical history should the nurse report to the provider?

• A. History of hypertension
• B. History of polycystic ovary syndrome
• C. History of asthma
• D. History of kidney disease

Correct answer: D

Rationale: The correct answer is D, history of kidney disease. Metformin should be used with caution in clients with kidney disease due to the risk of lactic acidosis, a serious complication. Reporting this finding to the provider is crucial for assessing the appropriateness of continuing metformin therapy. Choices A, B, and C do not contraindicate the use of metformin, so they are not the priority for reporting.

Similar Questions