Nursing Elites

1. Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?

• A. Transfuse Type A negative blood until type AB negative is available.
• B. Recheck the client’s hemoglobin, blood type, and Rh factor.
• C. Administer normal saline solution until type AB negative is available.
• D. Obtain additional consent for the administration of type A negative blood.

Correct answer: A

Rationale: In emergency situations where AB negative blood is unavailable, type A negative blood can be transfused to a patient with AB negative blood type. Type A negative blood is compatible with AB negative blood, making it a suitable option until the correct blood type becomes available. Transfusion of Type A negative blood is crucial to address the severe anemia promptly. Rechecking the client’s hemoglobin, blood type, and Rh factor (Choice B) may delay necessary treatment. Administering normal saline solution (Choice C) is not a substitute for blood transfusion in cases of severe anemia. Obtaining additional consent for the administration of type A negative blood (Choice D) is unnecessary as the situation is emergent and the blood type is compatible.

2. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.

3. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply)

• A. Decrease laxative use to every other day and use oil retention enemas as needed.
• B. Include oatmeal with stewed prunes for breakfast as often as possible.
• C. Increase fluid intake by keeping a water glass next to the recliner.
• D. Recommend seeking help with regular shopping and meal preparation.

Correct answer: C

Rationale: The correct answer is C. Increasing fluid intake is essential for managing constipation. Adequate hydration helps soften stool and promotes bowel movements. Choices A and B are incorrect as decreasing laxative use without medical advice and suggesting specific foods like oatmeal with stewed prunes may not be suitable for every individual with constipation. Choice D is also incorrect as while seeking help with meal preparation can indirectly aid in managing constipation, the immediate need is to increase fluid intake.

4. The parents of a 6-year-old recently diagnosed with asthma should be taught that the symptom of acute episodes of asthma is due to which physiological response?

• A. Inflammation of the mucous membrane & bronchospasm
• B. Increased mucus production and bronchoconstriction
• C. Allergic reactions and hyperventilation
• D. Airway narrowing and decreased lung capacity

Correct answer: A

Rationale: The correct answer is A: Inflammation of the mucous membrane & bronchospasm. Acute asthma episodes are primarily caused by inflammation of the airways and bronchospasm, which lead to airway obstruction. Increased mucus production and bronchoconstriction (Choice B) are part of the physiological responses in asthma but do not directly cause acute episodes. Allergic reactions and hyperventilation (Choice C) are related to asthma triggers and responses but are not the direct causes of acute episodes. Airway narrowing and decreased lung capacity (Choice D) are consequences of inflammation and bronchospasm but do not explain the physiological response leading to acute asthma episodes.

5. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?

• A. Assist the client in identifying goals for the day
• B. Encourage the client to participate in a team sport for one hour
• C. Schedule the client for a group session that focuses on self-esteem
• D. Help the client develop a list of daily affirmations

Correct answer: A

Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.

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