Nursing Elites

1. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

• A. Obtain informed consent from the client for the PRBC transfusion
• B. Review the client’s medical history for a history of transfusion reactions
• C. Assess the client’s baseline vital signs before starting the transfusion
• D. Verify the blood type and crossmatch with another licensed nurse

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

2. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?

• A. Drink clear liquids for 24 hours before the procedure
• B. Take a laxative the morning of the procedure
• C. Eat a light meal before the procedure
• D. Avoid drinking fluids for 4 hours before the procedure

Correct answer: A

Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.

3. During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

• A. Provide information about the hours and location of the chapel
• B. Document the statement in the client’s spiritual assessment
• C. Invite the client to a healing service for people of all religions
• D. Offer to contact a spiritual advisor of the client’s choice

Correct answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care. Providing information about the chapel's hours and location (choice A) may not align with the client's beliefs as an agnostic. Inviting the client to a healing service (choice C) assumes the client's interest in such activities, which may not be the case. Offering to contact a spiritual advisor (choice D) may not be necessary if the client did not express a desire for it.

4. A client has a nursing diagnosis of 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

• A. Help the client accept the final stage of life.
• B. Assist and support the client in establishing short-term goals.
• C. Encourage the client to make future plans, even if they are unrealistic.
• D. Instruct the client's family to focus on positive aspects of the client's life.

Correct answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress. Encouraging the client to make future plans, especially if they are unrealistic, may not be beneficial as it could lead to further distress if those plans are unattainable. Instructing the client's family to focus on positive aspects of the client's life, though supportive, does not directly address the client's spiritual distress and loss of hope.

5. When making the bed of a client who needs a bed cradle, which action should the nurse include?

• A. Teach the client to call for help before getting out of bed.
• B. Keep both the upper and lower side rails in a raised position.
• C. Keep the bed in the lowest position while changing the sheets.
• D. Drape the top sheet and covers loosely over the bed cradle.

Correct answer: D

Rationale: A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. This helps in maintaining the proper positioning and function of the bed cradle to ensure the client's comfort and safety during bed making.

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