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 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

• A. Allow the client to hear running water while attempting to void
• B. Provide the client with a bedpan while sitting upright
• C. Insert an indwelling urinary catheter and connect it to gravity drainage
• D. Encourage the client to limit fluid intake

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.

3. During an abdominal assessment for an adult client, what is the correct sequence of steps?

• A. Inspect, Auscultate, Percuss, Palpate
• B. Palpate, Percuss, Inspect, Auscultate
• C. Auscultate, Inspect, Percuss, Palpate
• D. Percuss, Palpate, Inspect, Auscultate

Correct answer: A

Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.

4. A client has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

• A. This type of hearing aid allows for fine-tuning of volume.
• B. I should ensure the hearing aid stays secure during exercise.
• C. I might hear a whistling sound when I first insert the hearing aid.
• D. I will be sure to remove my hearing aid before taking a shower.

Correct answer: D

Rationale: The correct answer is D because removing the hearing aid before taking a shower is essential to prevent water damage, as moisture can harm the device. Choice A is incorrect because behind-the-ear hearing aids do allow for fine-tuning of volume. Choice B is incorrect because exercise may cause the hearing aid to shift position, so it's important to ensure it stays secure. Choice C is incorrect because hearing a whistling sound when inserting the hearing aid may indicate improper placement or fit.

5. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

• A. "It might help me to listen to music while I'm lying in bed."
• B. "I will use the pain medication as prescribed to manage the pain."
• C. "I will request a different type of pain medication if the pain persists."
• D. "I will ask for a physical therapist to help with the pain."

Correct answer: A

Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.

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