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 nurse in a health clinic is caring for a 20-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client?

• A. Testicular examination
• B. Blood glucose
• C. Fecal occult blood
• D. Prostate-specific antigen

Correct answer: A

Rationale: A testicular examination is appropriate for a 20-year-old male to screen for testicular cancer, which is more common in younger age groups. Testicular cancer is most frequently diagnosed in individuals between the ages of 15 and 40. Blood glucose screening is typically recommended for older individuals or those at risk for diabetes. Fecal occult blood testing is used for colorectal cancer screening, usually starting at age 50. Prostate-specific antigen testing is commonly considered for prostate cancer screening in older males, typically around age 50. Therefore, the most appropriate screening for the 20-year-old client is the testicular examination.

3. When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?

• A. The client's stronger side holds the cane
• B. The top of the cane is parallel to the client's waist
• C. The client holds the cane on the stronger side of their body
• D. The client moves the cane 46 cm (18 in) forward

Correct answer: C

Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.

4. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?

• A. Assess the client's mobility
• B. Evaluate the pedal pulses
• C. Monitor skin temperature
• D. Check for swelling

Correct answer: B

Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.

5. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?

• A. Irrigate the tube with normal saline every shift.
• B. Check the tube placement by auscultation.
• C. Secure the tube to the client's gown.
• D. Flush the tube with 5 mL of sterile water before and after medication administration.

Correct answer: A

Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.

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