Nursing Elites

1. A healthcare professional is preparing to administer a transfusion of 300 mL of pooled platelets for a client who has severe Thrombocytopenia. How long should the healthcare professional plan to administer the transfusion over?

• A. Within 30 min/unit
• B. Within 60 min/unit
• C. Within 2 hr/unit
• D. Within 4 hr/unit

Correct answer: A

Rationale: Platelets are fragile components that must be administered quickly to maintain their effectiveness and minimize the risk of clumping. The recommended administration time for platelets is within 15 to 30 minutes per unit. This rapid administration helps ensure the platelets remain viable and functional for the client receiving the transfusion. Therefore, the correct answer is to administer the transfusion within 30 minutes per unit. Choices B, C, and D are incorrect as they exceed the recommended administration time for platelets, which could compromise their efficacy and pose risks to the client.

2. A client is reviewing a new prescription for Terbutaline with a history of preterm labor. Which of the following client statements indicates understanding of the teaching?

• A. I can increase my activity now that I've started on this medication.
• B. I will increase my daily fluid intake to 3 quarts.
• C. I will report increasing intensity of contractions to my doctor.
• D. I am glad this will prevent preterm labor.

Correct answer: C

Rationale: The correct answer is C. The client should report increasing intensity, frequency, or duration of contractions to the provider as these are signs of preterm labor. Monitoring contractions is crucial for the management of preterm labor and the safety of both the client and the fetus. Choices A, B, and D are incorrect because increasing activity, fluid intake, or assuming the medication will prevent preterm labor do not address the essential need to report changes in contractions, which are a vital sign of potential complications in preterm labor.

3. When caring for a client receiving treatment with irinotecan, which of the following findings should the nurse monitor?

• A. Diarrhea
• B. Hypertension
• C. Ototoxicity
• D. Neutropenia

Correct answer: A

Rationale: The correct answer is diarrhea. Irinotecan commonly causes diarrhea as an adverse effect due to its impact on the gastrointestinal tract. Monitoring for diarrhea is essential to prevent dehydration and manage this side effect effectively. Choices B, C, and D are incorrect as hypertension, ototoxicity, and neutropenia are not commonly associated with irinotecan therapy.

4. A healthcare professional is planning to administer IV Alteplase to a client who is demonstrating manifestations of a massive Pulmonary Embolism. Which of the following interventions should the healthcare professional plan to take?

• A. Administer IM Enoxaparin along with the Alteplase dose.
• B. Hold direct pressure on puncture sites for up to 30 min.
• C. Administer Aminocaproic acid IV prior to alteplase infusion.
• D. Prepare to administer Alteplase within 8 hr of manifestation onset.

Correct answer: B

Rationale: The correct intervention when administering IV Alteplase is to hold direct pressure on puncture sites for 10 to 30 minutes or until oozing of blood stops. This helps prevent bleeding complications associated with thrombolytic therapy. Administering IM Enoxaparin is not indicated with Alteplase, as it is an anticoagulant rather than a thrombolytic agent. Aminocaproic acid is not typically administered prior to alteplase infusion in the context of a massive Pulmonary Embolism. While timely administration of Alteplase is important, the specific timeframe within which it should be administered may vary based on the clinical situation, so a strict 8-hour window is not universally applicable.

5. A client has a prescription for a Nicotine transdermal patch. Which of the following instructions should the nurse include?

• A. Apply the patch at the same time each day.
• B. Remove the patch at bedtime.
• C. Apply the patch to the same location daily.
• D. Place the patch over an area of the body with hair.

Correct answer: A

Rationale: The correct instruction for a client using a Nicotine transdermal patch is to apply the patch at the same time each day. This helps maintain consistent blood levels of nicotine throughout the treatment period, which can aid in reducing cravings for smoking. Consistency in the application time is essential for the effectiveness of the patch. Choices B, C, and D are incorrect. Removing the patch at bedtime may disrupt the continuous delivery of nicotine, applying the patch to the same location daily can cause skin irritation, and placing the patch over an area with hair may affect its adhesion and absorption.

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