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. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?

• A. A client who is postoperative following a bowel resection with an NGT set to continuous suction.
• B. A client who has fractured a femur yesterday and is experiencing shortness of breath.
• C. A client who sustained a concussion and has unequal pupils.
• D. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.

Correct answer: A

Rationale: The correct answer is A because the LPN can care for stable clients with complex needs, such as managing an NGT set to continuous suction. Choices B, C, and D involve clients with more acute conditions that require a higher level of assessment and intervention, making them unsuitable for delegation to an LPN. Choice B requires prompt evaluation of the shortness of breath in a client with a recent femur fracture, which is beyond the LPN's scope. Choice C involves a head injury and unequal pupils, indicating the need for neurological assessment and close monitoring. Choice D relates to a critically low hemoglobin level and the need for blood transfusion, requiring careful monitoring and potential intervention beyond the LPN's role.

3. A client who has a new prosthesis for an above-the-knee amputation of the right leg needs teaching on its use. Which of the following instructions should the nurse include?

• A. Wear the prosthesis for 2 hours at a time
• B. Remove the prosthesis every other day
• C. Apply the prosthesis immediately upon waking each day
• D. Elevate the stump for 24 hours after applying the prosthesis

Correct answer: C

Rationale: The correct instruction is to apply the prosthesis immediately upon waking each day. This helps the client adjust to and maintain mobility. Choice A is incorrect because wearing the prosthesis for only 2 hours at a time may not be sufficient for proper adjustment. Choice B is incorrect as removing the prosthesis every other day is not a standard practice and may hinder the client's mobility. Choice D is incorrect because elevating the stump for 24 hours after applying the prosthesis is unnecessary and not a recommended practice.

4. A nurse is caring for a client who has been diagnosed with hyperkalemia. Which of the following findings should the nurse expect?

• A. Muscle weakness
• B. Nausea
• C. Increased thirst
• D. Restlessness

Correct answer: A

Rationale: Muscle weakness is a characteristic finding in hyperkalemia. High levels of potassium can affect the normal function of muscles, leading to weakness. Nausea and increased thirst are not typically associated with hyperkalemia. Restlessness is more commonly seen in conditions such as hypoxia or anxiety, not specifically in hyperkalemia.

5. What are the nursing priorities for a patient experiencing an asthma exacerbation?

• A. Administer a bronchodilator
• B. Encourage deep breathing
• C. Provide oxygen therapy
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.

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