Nursing Elites

1. What is the first step when administering a blood transfusion?

• A. Warm the blood to body temperature
• B. Verify the client's blood type before administration
• C. Administer the blood through an IV push
• D. Administer diuretics before the transfusion

Correct answer: B

Rationale: The correct answer is to verify the client's blood type before administration. This step is crucial to ensure compatibility and prevent adverse reactions such as hemolytic transfusion reactions. Warming the blood to body temperature (Choice A) is not the first step and is not typically done during blood transfusions. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow infusion. Administering diuretics before the transfusion (Choice D) is unnecessary and not a standard practice when initiating a blood transfusion.

2. What lifestyle change should be emphasized for a client with hypertension?

• A. Increase intake of dairy products
• B. Reduce caffeine and sodium intake
• C. Eat carbohydrate-rich meals
• D. Limit intake of leafy green vegetables

Correct answer: B

Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to reduce caffeine and sodium intake. Caffeine can temporarily raise blood pressure, and high sodium intake is linked to increased blood pressure levels. Therefore, reducing these two components can help manage blood pressure in individuals with hypertension. Choices A, C, and D are incorrect because increasing intake of dairy products, consuming carbohydrate-rich meals, and limiting intake of leafy green vegetables do not specifically address the factors that contribute to high blood pressure in hypertension.

3. During a presentation on basic first aid, a nurse educator evaluates a newly licensed home health nurse's understanding of heat stroke. Which symptom indicates the client has heat stroke?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke can lead to hypotension, which is low blood pressure. This is a common symptom of heat stroke and requires immediate intervention. Bradycardia (slow heart rate), clammy skin, and bradypnea (slow breathing) are not typically associated with heat stroke. In heat stroke, the body's temperature regulation system fails, leading to a rapid rise in body temperature, which can cause various symptoms including hypotension.

4. A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?

• A. Normal saline
• B. Hydrogen peroxide
• C. Iodine
• D. Alcohol

Correct answer: B

Rationale: The correct answer is B: Hydrogen peroxide. Hydrogen peroxide is commonly used to clean tracheostomy cannulas to prevent infection. Normal saline (choice A) is used for wound irrigation but not for cleaning inner cannulas of tracheostomy tubes. Iodine (choice C) and alcohol (choice D) are not recommended for cleaning tracheostomy cannulas as they can be too harsh and irritating to the delicate tissues of the airway.

5. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 150/80 mm Hg
• B. Swelling in the legs
• C. Persistent cough
• D. Heart rate of 72 beats per minute

Correct answer: C

Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.

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