Nursing Elites

1. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

• A. I will increase my intake of vitamin C.
• B. I will avoid alcohol and tobacco.
• C. I will need to take folic acid supplements.
• D. I will avoid taking any medication without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

2. The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?

• A. Lung sounds and respiratory status.
• B. Skin integrity and color.
• C. Neurological status and level of consciousness.
• D. Cardiac rate and rhythm.

Correct answer: D

Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.

3. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

4. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?

• A. request transport of the child to his pediatrician's office
• B. call the child's parents and send him home for the day
• C. compare the child's body mass index to normal values
• D. measure the child's pulse and blood pressure every 15 minutes

Correct answer: D

Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.

5. A homeless client with alcohol dependency will be dismissed from the emergency department in 24 hours. The nurse notes that a tuberculin skin test was prescribed by the healthcare provider. What intervention is most important for the nurse to implement prior to discharge?

• A. Identify how the client will follow-up to have the results read
• B. Give the client written information about the tuberculosis test
• C. Determine if the client understands the purpose of the tuberculin test
• D. Explain to the client results should be read between 48 and 72 hours

Correct answer: A

Rationale: The most important intervention for the nurse to implement prior to the discharge of a homeless client with alcohol dependency who had a tuberculin skin test prescribed is to identify how the client will follow-up to have the results read. This is crucial to ensure proper diagnosis and treatment. Providing written information (Choice B) is helpful but not as critical as ensuring the follow-up plan. Determining if the client understands the purpose of the test (Choice C) is important but not as immediate as ensuring the follow-up plan. Explaining when the results should be read (Choice D) is important, but the priority is to make sure the client has a plan in place for follow-up.

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