Nursing Elites

1. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?

• A. Record usual eating patterns
• B. Evaluate for muscle cramping
• C. Document abdominal girth
• D. Elevate both legs on pillows

Correct answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.

2. During a blood transfusion, which sign or symptom should prompt the healthcare provider to immediately stop the transfusion?

• A. Slight increase in blood pressure
• B. Elevated temperature and chills
• C. Mild nausea
• D. Slight headache

Correct answer: B

Rationale: The correct answer is B: Elevated temperature and chills. These symptoms are indicative of a transfusion reaction, which can be severe and life-threatening. It is crucial to stop the transfusion immediately and notify the healthcare provider for further assessment and management. Elevated temperature and chills are classic signs of a transfusion reaction, specifically indicating a possible febrile non-hemolytic reaction. Choice A, a slight increase in blood pressure, is not typically a reason to stop a transfusion unless it is a significant sudden increase. Mild nausea (Choice C) and a slight headache (Choice D) are common side effects of blood transfusions and are not primary indicators of a transfusion reaction that require immediate cessation of the transfusion.

3. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement?

• A. Stimulate the infant to cry
• B. Give oxygen by positive pressure
• C. Suction the oral and nasal passages
• D. Turn the infant onto the right side

Correct answer: C

Rationale: Suctioning the oral and nasal passages is the correct immediate intervention in this scenario. Regurgitation leading to cyanosis indicates a potential airway obstruction, which requires prompt action to clear. Stimulating the infant to cry (Choice A) may not address the underlying issue of airway obstruction. Giving oxygen by positive pressure (Choice B) can be beneficial, but clearing the airway obstruction takes precedence. Turning the infant onto the right side (Choice D) does not directly address the need to clear the airway.

4. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the PN document as evidence that the amount of insulin is inadequate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dL
• D. Reports nausea in the morning but can still eat breakfast

Correct answer: C

Rationale: The correct answer is C. High evening glucose levels indicate that the morning dose of NPH insulin may be insufficient to control blood sugar throughout the day. Choice A is incorrect as cold and numb feet are more indicative of a circulation issue rather than an insulin inadequacy. Choice B suggests a wound infection rather than inadequate insulin. Choice D, nausea in the morning, may be due to other causes and does not necessarily indicate inadequate insulin dosage.

5. A 12-year-old child is receiving a blood transfusion via an infusion pump and begins to complain of 'itchy' skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the nurse take first?

• A. Apply lotion to the skin
• B. Stop the transfusion
• C. Inspect the infusion site
• D. Obtain the vital signs

Correct answer: B

Rationale: Stopping the transfusion immediately is crucial when signs of a transfusion reaction, such as itching and flushing, occur. This action is taken to prevent further exposure to the potentially harmful transfused blood. Applying lotion to the skin, inspecting the infusion site, or obtaining vital signs can be important but are secondary to stopping the transfusion to ensure the safety of the child. Applying lotion may not address the underlying issue of a possible transfusion reaction. Inspecting the infusion site and obtaining vital signs can be done after stopping the transfusion, as patient safety is the top priority in this situation.

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