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. A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?

• A. Figs
• B. Broccoli
• C. Stewed tomatoes
• D. Skim milk

Correct answer: D

Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.

3. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

• A. Neurological status
• B. Cardiac status
• C. Respiratory status
• D. Gastrointestinal status

Correct answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

4. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

• A. Glycerin suppositories
• B. Fiber supplements
• C. Laxatives
• D. Stool softeners

Correct answer: C

Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.

5. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?

• A. Pulverize all medications into a powdery condition
• B. Squeeze the tube before using it to break up stagnant liquids
• C. Cleanse the skin around the tube daily with hydrogen peroxide
• D. Flush adequately with water before and after using the tube

Correct answer: D

Rationale: For a client with a percutaneous endoscopic gastrostomy (PEG) tube, flushing the tube adequately with water before and after use is essential. This action helps prevent clogging and ensures the proper administration of feedings and medications. Choice A is incorrect because pulverizing all medications into a powdery condition is not necessary for PEG tube administration. Choice B is incorrect as squeezing the tube to break up stagnant liquids may damage the tube. Choice C is incorrect because cleansing the skin around the tube daily with hydrogen peroxide can be too harsh and lead to skin irritation.

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