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. A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?

• A. Administer diphenhydramine (Benadryl)
• B. Discontinue the antibiotic infusion
• C. Apply a cool compress to the rash
• D. Notify the healthcare provider

Correct answer: B

Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.

3. A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?

• A. It decreases the risk of injecting medication into a blood vessel.
• B. It delays medication absorption.
• C. It minimizes tissue irritation.
• D. It accelerates medication excretion.

Correct answer: C

Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.

4. The healthcare professional is caring for a client who is post-operative following a hip replacement. Which assessment finding would require immediate intervention?

• A. Pain at the surgical site
• B. Swelling in the affected leg
• C. Elevated temperature
• D. Shortness of breath

Correct answer: D

Rationale: Shortness of breath is a critical assessment finding that could indicate a pulmonary embolism or other serious complication related to surgery, such as a respiratory issue or cardiac problem. Immediate intervention is necessary to prevent further complications or harm to the client. Pain at the surgical site is common post-operatively and can be managed with appropriate pain relief measures. Swelling in the affected leg is expected after a hip replacement and can often be managed conservatively or monitored closely. An elevated temperature could be a sign of infection, which is important to address but may not require immediate intervention unless other symptoms of sepsis are present.

5. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

• A. Hypostatic pneumonia
• B. Renal stones
• C. Pressure ulcers
• D. Thrombus formation

Correct answer: B

Rationale: The correct answer is B: Renal stones. Renal calculi are calcium stones that can form in the renal pelvis or pass through the ureters. Immobilized patients, who have hypercalcemia, are at increased risk for developing renal stones. Monitoring for signs and symptoms of renal stones is crucial in this patient population. Choices A, C, and D are incorrect because although they are potential complications in immobilized patients, they are not directly associated with hypercalcemia and do not match the scenario described in the question.

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