Nursing Elites

1. Which finding should the nurse report immediately for a client receiving a blood transfusion?

• A. Mild itching and rash
• B. Temperature increase of 1.5°F (0.8°C)
• C. Heart rate increase of 10 beats per minute
• D. Slight headache

Correct answer: B

Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.

2. A client with chronic kidney disease is receiving epoetin alfa. Which laboratory value should the nurse monitor to determine the effectiveness of the treatment?

• A. Blood urea nitrogen (BUN)
• B. Serum creatinine
• C. Hemoglobin and hematocrit
• D. Serum potassium

Correct answer: C

Rationale: The correct answer is C: Hemoglobin and hematocrit. Epoetin alfa is a medication that stimulates red blood cell production, so monitoring hemoglobin and hematocrit levels is essential to assess its effectiveness. These values reflect the oxygen-carrying capacity of the blood and can indicate if the treatment is improving anemia related to chronic kidney disease. Choices A, B, and D are incorrect. Blood urea nitrogen (BUN) and serum creatinine are indicators of kidney function, while serum potassium levels are monitored due to electrolyte imbalances commonly seen in kidney disease, but they do not directly reflect the effectiveness of epoetin alfa.

3. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

• A. Assist with personal care, but leave oral care for the nurse to complete.
• B. Provide a soft bristle brush for the client to use during oral care.
• C. Use alcohol-based mouthwash to clean the ulcers.
• D. Apply an antifungal cream to the mouth ulcers.

Correct answer: B

Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.

4. A client with liver cirrhosis is at risk for developing hepatic encephalopathy. Which clinical manifestation should the nurse monitor for?

• A. Kussmaul respirations
• B. Asterixis (flapping tremor)
• C. Bradycardia
• D. Hypertension

Correct answer: B

Rationale: Corrected Rationale: Asterixis, also known as a flapping tremor, is a common sign of hepatic encephalopathy, indicating neurological dysfunction due to liver failure. Kussmaul respirations (option A) are associated with metabolic acidosis, which is not a typical manifestation of hepatic encephalopathy. Bradycardia (option C) and hypertension (option D) are not typically associated with hepatic encephalopathy; in fact, hepatic encephalopathy is more commonly associated with alterations in mental status, neuromuscular abnormalities, and changes in behavior.

5. The family of a newly admitted child with cystic fibrosis is educated by the nurse that the treatment will be centered on what therapy?

• A. Chest physiotherapy
• B. Mucus-drying agents
• C. Prevention of diarrhea
• D. Insulin therapy

Correct answer: A

Rationale: The correct answer is A: Chest physiotherapy. In cystic fibrosis, chest physiotherapy and aerosol medications are fundamental components of treatment to help clear mucus from the lungs, reduce the risk of infections, and improve breathing. Mucus-drying agents (Choice B) are not typically used in the treatment of cystic fibrosis. Prevention of diarrhea (Choice C) is not a primary focus in the treatment of cystic fibrosis. Insulin therapy (Choice D) is not relevant to cystic fibrosis, as it is a treatment for diabetes.

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