Nursing Elites

1. The nurse is preparing to administer a blood transfusion to a client. Which action should the LPN/LVN take to ensure the client's safety?

• A. Check the client's identification and blood type.
• B. Monitor the client's vital signs every hour during the transfusion.
• C. Administer the blood through a peripheral IV line.
• D. Verify the blood product with another nurse before administration.

Correct answer: D

Rationale: To ensure the client's safety during a blood transfusion, it is crucial to verify the blood product with another nurse before administration. This step helps confirm the correct blood type and prevents transfusion reactions. While checking the client's identification and blood type (Choice A) is important, the ultimate responsibility lies with confirming the blood product before administration. Monitoring vital signs (Choice B) is necessary during a transfusion but does not directly address verifying the blood product. Administering blood through a peripheral IV line (Choice C) is a common practice but does not specifically ensure that the correct blood product is being administered, which is essential for the client's safety.

2. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to:

• A. Sit and hold the client’s hand
• B. Ask why the client is crying
• C. Leave the room to give the client privacy
• D. Administer the medications and leave

Correct answer: A

Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.

3. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.

4. A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?

• A. Ensure that the width of the BP cuff is appropriate for the client's arm circumference.
• B. Reposition the client supine and recheck their BP.
• C. Recheck the client's BP and measure their other arm for comparison.
• D. Request that another nurse check the client's BP in 30 minutes.

Correct answer: C

Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.

5. A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy with alcohol.
• C. Replace the tracheostomy tube every week.
• D. Cover the tracheostomy with a wet cloth when sleeping.

Correct answer: A

Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.

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