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 patient is placed in the Sims' position. Which areas will the nurse observe for pressure points?

• A. Chin, elbow, hips
• B. Ileum, clavicle, humerus
• C. Shoulder, anterior iliac spine, ankles
• D. Occipital region of the head, coccyx, heels

Correct answer: B

Rationale: When a patient is placed in the Sims' position, the nurse should observe pressure points on the ileum, clavicle, humerus, knees, and ankles. Choice A is incorrect as the chin and hips are not typically pressure points in the Sims' position. Choice C is incorrect as the shoulder and anterior iliac spine are not commonly observed pressure points in this position. Choice D is also incorrect as the occipital region of the head, coccyx, and heels are not pressure points commonly associated with the Sims' position.

3. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

• A. Administer antibiotic therapy for 10 days
• B. Teach the client isometric exercises for legs
• C. Assess movement and sensation of extremities
• D. Assist the client to stand up at the bedside within the first 24 hours

Correct answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

4. When a client decides not to have surgery despite significant blockages of the coronary arteries, it is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Nonmaleficence

Correct answer: B

Rationale: The correct answer is autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their healthcare, including the choice to refuse treatment or surgery. In this scenario, the client's decision not to have surgery despite the recommendation is an exercise of autonomy. Choice A, fidelity, refers to being faithful and keeping promises, which is not applicable in this situation. Choice C, justice, pertains to fair and equal distribution of resources and treatment, not the individual's right to make decisions. Choice D, nonmaleficence, relates to the obligation to do no harm, which is not directly applicable to the client's decision to refuse surgery.

5. A healthcare professional is preparing to administer gentamicin 2 mg/kg via IV bolus to a client who weighs 220 lb. How many mg should the healthcare professional administer?

• A. 200 mg
• B. 100 mg
• C. 160 mg
• D. 180 mg

Correct answer: C

Rationale: To calculate the dosage correctly, the weight in pounds must first be converted to kilograms. 220 lb / 2.2 = 100 kg. Then, multiply the weight in kg by the dosage of 2 mg/kg: 2 mg/kg × 100 kg = 200 mg. Therefore, the correct dosage to administer is 200 mg, which is closest to option A. Option C (160 mg) is incorrect because it does not match the calculated dosage. Options B (100 mg) and D (180 mg) are also incorrect as they do not align with the correct calculation.

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