Nursing Elites

1. During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?

• A. The client reports feeling warm and flushed.
• B. The client develops a rash on the chest and back.
• C. The client experiences chills and a fever.
• D. The client complains of back pain and shortness of breath.

Correct answer: D

Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.

2. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?

• A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
• B. I can use alcohol-based hand rub after using the restroom.
• C. Soap and water are only necessary if my hands are visibly dirty.
• D. Hand rub is always sufficient, regardless of the situation.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.

3. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?

• A. The parents' name and telephone number
• B. The currency of the immunization and allergy history of the child
• C. The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance
• D. The affected child's age and weight

Correct answer: D

Rationale: In the event of accidental poisoning, it is crucial to know the child's age and weight to determine the appropriate treatment. This information helps healthcare providers calculate the correct dosage of antidotes or medications needed based on the child's size and age. The child's age and weight play a significant role in managing accidental poisoning cases. Therefore, this information should be a priority for parents to communicate in such emergencies. Choices A, B, and C are not as critical as the child's age and weight when it comes to immediate treatment decisions for accidental poisoning.

4. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

• A. Members of the same religion may have varying feelings about their religion.
• B. A shared religion background does not guarantee identical beliefs.
• C. The same religious beliefs can influence individuals differently.
• D. Discussing differences and commonalities in beliefs may not always be relevant.

Correct answer: C

Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.

5. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Murmur
• C. S1 and S2
• D. Bruit

Correct answer: A

Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.

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