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. What is the most suitable snack food for the LPN/LVN to offer a client with myasthenia gravis who is at risk for altered nutritional status?

• A. Chocolate pudding.
• B. Graham crackers.
• C. Sugar-free gelatin.
• D. Apple slices.

Correct answer: A

Rationale: Chocolate pudding is the best snack food choice for a client with myasthenia gravis at risk for altered nutritional status due to its nutrient density and soft texture, which can be easier for clients with swallowing difficulties to consume. Graham crackers, sugar-free gelatin, and apple slices may not provide the same level of nutrient density or ease of consumption for these clients. Graham crackers and apple slices may also pose challenges for clients with swallowing difficulties, while sugar-free gelatin, although a good option for some clients, may not offer the same level of nutrition as chocolate pudding.

3. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?

• A. Encourage the client to relax and take deep breaths during the dressing change.
• B. Educate the client about the importance of pain management postoperatively.
• C. Assist the client to a comfortable position for the dressing change.
• D. Administer pain medication 45 minutes before changing the client's dressing.

Correct answer: D

Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.

4. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

• A. Administer pain medication 45 minutes before changing the client’s dressing.
• B. Change the dressing less frequently.
• C. Apply a topical anesthetic before removing the dressing.
• D. Use a non-adherent dressing to reduce pain.

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

5. A client with herpes zoster asks the nurse about using complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

• A. Biofeedback
• B. Aloe
• C. Feverfew
• D. Acupuncture

Correct answer: D

Rationale: Acupuncture is contraindicated for clients with herpes zoster due to the risk of introducing an open portal on the skin, which can increase the risk of infection. This therapy involves inserting needles into specific points on the body, potentially causing skin trauma and providing a route for the virus to spread. Biofeedback, aloe, and feverfew are not contraindicated for clients with herpes zoster and can be considered for pain management in this condition. Biofeedback involves using electronic devices to help individuals learn to control physiological processes, aloe is a plant known for its skin-soothing properties, and feverfew is an herb that has been used for pain relief.

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