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 has C-diff infection. Which of the following actions should the nurse take?

• A. Give the client chlorhexidine gluconate for hand hygiene.
• B. Remove the protective gown first when exiting the client's room.
• C. Use alcohol-based hand rub when caring for the client.
• D. Initiate contact precautions when providing client care.

Correct answer: D

Rationale: The correct answer is to initiate contact precautions when providing client care. C-diff (Clostridium difficile) is highly contagious, and contact precautions are necessary to prevent its spread. Giving the client chlorhexidine gluconate for hand hygiene (Choice A) is not specific to managing C-diff. Removing the protective gown first when exiting the client's room (Choice B) may increase the risk of contaminating oneself and the environment. Using alcohol-based hand rub when caring for the client (Choice C) is not sufficient to prevent the transmission of C-diff, as soap and water are more effective against this particular pathogen.

3. 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.

4. A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.

5. When preparing an injection for opioid medication, a nurse draws 1mL from a 2mL vial. What should the nurse do next?

• A. Ask another nurse to observe medication wastage
• B. Document the amount of medication drawn on the MAR
• C. Dispose of the remaining medication in a sharps container
• D. Administer the entire vial of medication to avoid wastage

Correct answer: A

Rationale: When drawing medication from a vial, especially for controlled substances like opioids, any wastage must be witnessed by another healthcare professional to ensure accuracy, prevent diversion, and maintain safety standards. This process is crucial for proper documentation and accountability. Recording the amount drawn on the Medication Administration Record (MAR) is important for tracking administered doses and preventing errors. Disposing of the remaining medication in a sharps container is not recommended as it does not address proper wastage documentation. Administering the entire vial of medication just to avoid wastage is inappropriate and can lead to potential harm or overdose in the patient.

Similar Questions