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 should a healthcare professional assess in a patient presenting with symptoms of a stroke?

• A. Assess facial drooping
• B. Monitor speech difficulties
• C. Evaluate arm weakness
• D. Check for time of onset of symptoms

Correct answer: A

Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.

3. What is the most important step when preparing to administer a blood transfusion?

• A. Check if the client has a fever
• B. Ensure the blood type is compatible with the client
• C. Administer the blood via IV push
• D. Ensure the blood is warmed to body temperature

Correct answer: B

Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.

4. A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?

• A. Give a bedtime snack
• B. Encourage a short nap in the afternoon
• C. Encourage exercise right before bed
• D. Establish a regular exercise routine 2 hours or more before bedtime

Correct answer: D

Rationale: The correct answer is D. Establishing a regular exercise routine at least 2 hours before bedtime promotes better sleep in older adults. Giving a bedtime snack (choice A) may disrupt sleep due to digestion, encouraging a short nap in the afternoon (choice B) can interfere with nighttime sleep, and encouraging exercise right before bed (choice C) can increase alertness and make it harder to fall asleep.

5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

• A. Wear sterile gloves when removing the old dressing
• B. Warm the irrigation solution to 40.5°C (105°F)
• C. Cleanse the wound from the center outwards
• D. Use a 20 mL syringe to irrigate the wound

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a prescription for wound irrigation is to cleanse the wound from the center outwards. This technique helps prevent contamination by pushing debris away from the wound rather than into it. Choice A is incorrect because wearing sterile gloves is important during wound care but not specifically mentioned for wound irrigation. Choice B is incorrect because warming the irrigation solution to a specific temperature is not a standard recommendation and can potentially harm the client. Choice D is incorrect because the size of the syringe may vary based on the wound size and depth, so using a 20 mL syringe is not a universal guideline.

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