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 nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor the client's electrolyte levels daily
• B. Weigh the client daily
• C. Monitor the client's blood glucose levels every 6 hours
• D. Change the TPN tubing every 24 hours

Correct answer: D

Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.

3. A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

• A. Tomatoes
• B. Carrots
• C. Avocados
• D. Apricots

Correct answer: A

Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.

4. What is the most appropriate strategy for a client with an NG tube who is experiencing nausea and decreased gastric secretions?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client onto their side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: Irrigating the NG tube with sterile water is the most appropriate strategy for a client with an NG tube experiencing nausea and decreased gastric secretions. This intervention helps in relieving blockages within the tube and can help reduce nausea by ensuring proper drainage. Increasing the suction pressure (Choice A) can lead to complications and should not be done without healthcare provider orders. Turning the client onto their side (Choice C) is a general measure for patient comfort but does not directly address the issue with the NG tube. Replacing the NG tube with a new one (Choice D) is not necessary unless there are specific indications like tube damage or dislodgement.

5. What are the key components of a focused respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Observation, Percussion, Auscultation, Palpation
• C. Auscultation, Palpation, Observation, Percussion
• D. Palpation, Inspection, Auscultation, Percussion

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for any abnormalities, palpating to assess tenderness and chest expansion, percussion to evaluate underlying structures, and auscultation to listen to lung sounds. Choice B is incorrect because observation is generally part of inspection, not a separate component. Choice C is incorrect as auscultation should come before percussion in a respiratory assessment. Choice D is incorrect because inspection should precede palpation in a structured assessment.

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