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. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

3. An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse’s attitude as challenging and offensive. What action is best for the nurse manager to take?

• A. Have both nurses meet separately with the staff mental health consultant
• B. Listen actively to both nurses and offer suggestions to solve the dilemma
• C. Ask the senior nurse to examine mentoring strategies used with the new graduate
• D. Ask the nurses to meet with the nurse-manager to identify ways of working together

Correct answer: D

Rationale: In this scenario, the best action for the nurse manager to take is to ask the nurses to meet with the nurse-manager to identify ways of working together. This approach promotes open communication, facilitates understanding of both perspectives, and encourages collaborative problem-solving. Option A is not ideal as involving a mental health consultant may be premature for this situation. Option B, although helpful in listening to both parties, does not directly address the need for collaboration. Option C focuses on the senior nurse's mentoring strategies only, rather than addressing the conflict between the two nurses.

4. Which client is at the greatest risk for developing delirium?

• A. An adult client who cannot sleep due to constant pain
• B. An older client who attempted suicide 1 month ago
• C. A young adult who takes antipsychotic medications twice a day
• D. A middle-aged woman who uses a tank for supplemental oxygen

Correct answer: B

Rationale: The correct answer is B because older adults are at higher risk for delirium, especially following a recent suicide attempt, which can be a significant stressor. Choice A is less likely to develop delirium solely due to difficulty sleeping; delirium is more complex and multifactorial. Choice C, a young adult taking antipsychotic medications, may be at risk for other conditions but not necessarily delirium. Choice D, a middle-aged woman using supplemental oxygen, is not directly linked to an increased risk of delirium compared to the older client who recently attempted suicide.

5. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

• A. Working together can decrease the risk of back injury.
• B. The technique is intended to maintain straight spinal alignment.
• C. Using two or three people increases client safety.
• D. Turning instead of pulling reduces the likelihood of skin damage.

Correct answer: B

Rationale: The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.

Similar Questions