Nursing Elites

1. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

• A. Asks the client to both say and spell their full name before starting the blood transfusion
• B. Ensures that another qualified healthcare professional checks the unit before administering
• C. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
• D. Ensures that all staff wear appropriate personal protective equipment during the transfusion process

Correct answer: C

Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.

2. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

• A. Call the healthcare provider and report the finding.
• B. Reassess the client’s blood pressure at the next follow-up appointment.
• C. Administer an additional antihypertensive medication to the client.
• D. Teach the client lifestyle modifications to decrease blood pressure.

Correct answer: D

Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.

3. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select one that doesn't apply.)

• A. Have suction equipment at the bedside
• B. Keep bed rails up at all times
• C. Ensure that the client has IV access
• D. Maintain the client on strict bed rest

Correct answer: D

Rationale: For a client with epilepsy, it is essential to avoid restraining them with strict bed rest as it can lead to complications like muscle atrophy, thrombosis, and pressure ulcers. Having suction equipment at the bedside is important in case of seizures to prevent aspiration. Keeping bed rails up can prevent falls during a seizure. Ensuring that the client has IV access is crucial for administering medications such as antiepileptic drugs or emergency medications if needed. Therefore, maintaining the client on strict bed rest is not a recommended precaution for a client with epilepsy.

4. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

5. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

• A. Document the observation in the chart.
• B. Measure urine specific gravity and volume.
• C. Assess the pulse and blood pressure.
• D. Assess the client's deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

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