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. A healthcare professional is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, and HCO3 22 mm Hg. The healthcare professional should recognize that the client is experiencing which of the following acid-base imbalances?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.

3. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

• A. SaO2 95%
• B. Wheezing
• C. Retraction of sternal muscles
• D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

4. The healthcare provider orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?

• A. 5 gtt/minute
• B. 13 gtt/minute
• C. 25 gtt/minute
• D. 50 gtt/minute

Correct answer: C

Rationale: To determine the flow rate in drops per minute, multiply the ordered volume per hour by the drop factor (100 ml/hour x 15 gtt/ml = 1500 gtt/hour). Then, divide the result by 60 minutes to convert it to drops per minute (1500 gtt/hour ÷ 60 minutes = 25 gtt/minute). Therefore, the correct answer is 25 gtt/minute.

5. A client with heart failure has a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Educating the client on the importance of rising slowly when getting out of bed is crucial due to the risk of orthostatic hypotension associated with furosemide use. This precaution helps prevent dizziness and falls. Options A and D are incorrect as furosemide commonly causes hypokalemia and dehydration, respectively, rather than high potassium levels or overhydration. Option B is inaccurate as clients on furosemide need to reduce sodium intake to manage fluid retention.

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