Nursing Elites

1. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow the rate of transfusion.
• B. Administer an antipyretic.
• C. Stop the transfusion immediately.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

2. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?

• A. Use short, simple sentences and maintain a calm demeanor
• B. Involve family members to provide reassurance
• C. Offer choices to empower the client
• D. All of the above

Correct answer: D

Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.

3. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?

• A. Recheck the radial pulse in thirty minutes
• B. Palpate the radial pulse for thirty seconds and double the rate
• C. Count the apical pulse rate for sixty seconds
• D. Compare the radial pulse rate bilaterally and record the higher rate

Correct answer: C

Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.

4. During a community health fair, a nurse is providing education on the effects of smoking. What is the most important information to include?

• A. Smoking can lead to cosmetic issues like tooth staining.
• B. Smoking is a leading cause of preventable death worldwide.
• C. Smoking temporarily elevates mood and alertness.
• D. Smoking is an expensive habit.

Correct answer: B

Rationale: The correct answer is B: 'Smoking is a leading cause of preventable death worldwide.' This information is crucial as it highlights the severe health risks associated with smoking, emphasizing the importance of cessation for overall health. Choice A is incorrect because cosmetic issues like tooth staining are not as significant as the life-threatening consequences of smoking. Choice C is incorrect because although smoking may temporarily elevate mood and alertness due to nicotine, this does not outweigh the serious health implications. Choice D is incorrect as while smoking is indeed an expensive habit, the focus should be on the health-related consequences to stress the urgency of quitting.

5. A client complains of pain at the IV site. Upon assessment, the nurse notes the site is warm, red, and swollen. What is the most likely cause of these findings?

• A. Phlebitis
• B. Infiltration
• C. Allergic reaction
• D. Fluid overload

Correct answer: A

Rationale: The correct answer is A, Phlebitis. Phlebitis is the inflammation of a vein, often caused by irritation from an IV catheter, resulting in warmth, redness, and swelling at the site. Infiltration (choice B) refers to the leaking of IV fluids into the surrounding tissues, causing swelling and pallor, not redness and warmth like in the scenario described. An allergic reaction (choice C) would present with itching, hives, or anaphylaxis, rather than localized warmth, redness, and swelling. Fluid overload (choice D) typically manifests as generalized edema, shortness of breath, and weight gain, not localized symptoms at the IV site.

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