Nursing Elites

1. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.

2. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

• A. Nausea and vomiting
• B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
• C. Diffuse macular rash
• D. Muscle tenderness

Correct answer: B

Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.

3. A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?

• A. Changing the TPN tubing and solution every 24 hours
• B. Monitoring the TPN infusion rate closely
• C. Keeping the head of the bed elevated
• D. Ensuring the solution is at room temperature before infusing

Correct answer: A

Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.

4. A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?

• A. Boiled rice
• B. Italian bread
• C. Broiled salmon filet
• D. Pickled beets

Correct answer: D

Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.

5. A client with diabetes is being educated about the dietary source that should provide the greatest percentage of their calories. Which of the following statements by the client indicates an understanding of the teaching?

• A. Most of my calories each day should be from fats.
• B. I should eat more calories from complex carbohydrates than anything else.
• C. Simple sugars are needed more than other calorie sources.
• D. Protein should be my main source of calories.

Correct answer: B

Rationale: The correct answer is B. In diabetes management, complex carbohydrates should constitute the largest portion of the diet as they help in maintaining steady energy levels and managing blood sugar. Choice A is incorrect because a high-fat diet can lead to complications in diabetes. Choice C is incorrect as simple sugars can cause rapid spikes in blood sugar levels. Choice D is incorrect as protein, while important, should not be the main source of calories for a diabetic individual.

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