Nursing Elites

1. A nurse is preparing to administer a blood transfusion. What is the first action?

• A. Administer the blood through an IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Ensure the client eats before starting the transfusion

Correct answer: B

Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.

2. A client has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

• A. Place the tablet under the tongue and wait 10 minutes
• B. Take up to five tablets during an angina episode
• C. Take up to three tablets during a single angina episode
• D. Swallow the tablet with water

Correct answer: C

Rationale: The correct answer is C: 'Take up to three tablets during a single angina episode.' Nitroglycerin can be taken up to three times during an episode to relieve angina. Choice A is incorrect because the client should place the tablet under the tongue and wait for it to dissolve, not wait for 10 minutes. Choice B is incorrect because taking up to five tablets during an angina episode is excessive and not recommended. Choice D is incorrect because nitroglycerin tablets are meant to be taken sublingually, not swallowed.

3. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?

• A. Insert the suppository 1 cm into the rectum
• B. Insert the suppository 2 cm into the rectum
• C. Insert the suppository past the anal sphincters
• D. Insert the suppository using two fingers

Correct answer: C

Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.

4. What are the key components of a focused respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Observation, Percussion, Auscultation, Palpation
• C. Auscultation, Palpation, Observation, Percussion
• D. Palpation, Inspection, Auscultation, Percussion

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for any abnormalities, palpating to assess tenderness and chest expansion, percussion to evaluate underlying structures, and auscultation to listen to lung sounds. Choice B is incorrect because observation is generally part of inspection, not a separate component. Choice C is incorrect as auscultation should come before percussion in a respiratory assessment. Choice D is incorrect because inspection should precede palpation in a structured assessment.

5. When caring for a client experiencing delirium, which of the following is essential?

• A. Controlling behavioral symptoms with low-dose psychotropics
• B. Identifying the underlying causative condition or illness
• C. Manipulating the environment to increase orientation
• D. Decreasing or discontinuing all previously prescribed medications

Correct answer: B

Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.

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