Nursing Elites

1. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:

• A. to rule out pneumothorax
• B. to rule out any possible perforation
• C. to decongest
• D. to rule out any foreign body

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. Select all that apply. Which nutrients are needed by the body to make hemoglobin?

• A. Iron
• B. Vitamin B12
• C. Niacin
• D. Folate

Correct answer: A

Rationale: The correct answer is A: Iron. Iron is an essential nutrient needed by the body to make hemoglobin, the protein in red blood cells that carries oxygen. While other nutrients like vitamin B12, niacin, and folate are important for various bodily functions, they are not directly involved in the production of hemoglobin. Vitamin B12 is essential for nerve function and DNA synthesis, niacin is important for metabolism, and folate is crucial for cell division and DNA synthesis. Therefore, only iron is specifically required for hemoglobin production.

3. To ensure client safety before starting blood transfusions, the following are needed before the procedure can be done EXCEPT:

• A. take baseline vital signs
• B. warm the blood to room temperature for 30 minutes before administering the transfusion
• C. have two nurses verify client identification, blood type, unit number, and expiration date of blood
• D. get consent signed for blood transfusion

Correct answer: D

Rationale: To ensure client safety before starting blood transfusions, taking baseline vital signs, warming the blood to room temperature, and having two nurses verify client identification, blood type, unit number, and expiration date of blood are crucial steps. Consent for blood transfusion is required but is typically obtained before the procedure. The focus before the procedure should be on confirming the right client, blood product, and ensuring the blood is prepared correctly to minimize risks of transfusion reactions.

4. Which of the following amino acids are considered indispensable?

• A. Lysine
• B. Methionine
• C. Tryptophan
• D. Valine

Correct answer: A

Rationale: The correct answer is A: Lysine. Indispensable amino acids are those that the body cannot synthesize and must be obtained from the diet. Lysine, methionine, and tryptophan are all examples of indispensable amino acids. However, the question specifically asked for 3 out of the 9 indispensable amino acids, making 'Lysine' the correct choice. Choices B, C, and D are also indispensable amino acids but are not the focus of the question.

5. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

Similar Questions