Nursing Elites

1. A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the professional take to identify the client?

• A. Match the client's blood type with the type and cross-match specimens
• B. Confirm the provider's prescription matches the number on the blood component
• C. Ask the client to state their blood type and the date of their last blood donation
• D. Ensure that the client's identification band matches the number on the blood unit

Correct answer: A

Rationale: When preparing to administer an autologous blood product, it is crucial to correctly identify the client to prevent errors. Matching the client's blood type with the type and cross-match specimens ensures that the blood product is intended for the correct recipient. This step helps in verifying the patient's identity and avoiding any transfusion-related complications. Confirming the blood type through type and cross-matching is a standard practice to ensure patient safety during blood transfusions.

2. Palpating the midclavicular line is the correct technique for assessing

• A. Baseline vital signs
• B. Systolic blood pressure
• C. Respiratory rate
• D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

3. Which of the following interventions is considered the most effective form of universal precautions?

• A. Cap all used needles before removing them from their syringes
• B. Discard all used uncapped needles and syringes in an impenetrable protective container
• C. Wear gloves when administering IM injections
• D. Follow enteric precautions

Correct answer: B

Rationale: The most effective form of universal precautions is to discard all used uncapped needles and syringes in an impenetrable protective container. This practice minimizes the risk of needle-stick injuries, which are a significant concern when dealing with used needles. By safely disposing of uncapped needles, healthcare providers can protect themselves and others from potential exposure to bloodborne pathogens.

4. A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

• A. Antibiotic
• B. Beta-blocker
• C. Antiviral
• D. Beta2 agonist

Correct answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

5. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room.
• B. Place the client in a room with negative pressure.
• C. Wear gloves when providing care to the client.
• D. Wear a mask when in the client's room.

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

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