Nursing Elites

1. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

2. Which pulse's absence may not be a significant finding when a patient is admitted to the hospital?

• A. Apical
• B. Radial
• C. Pedal
• D. Femoral

Correct answer: C

Rationale: The absence of the pedal pulse may not be significant if the patient has poor peripheral circulation or if the healthcare provider is focused on other pulse points. The pedal pulse is often weaker and may not always be palpable due to various factors, making its absence less concerning in certain situations. However, the absence of other pulses like radial or femoral pulses may indicate more critical conditions and require immediate attention.

3. A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

• A. Teach the client to scan the right to see objects on the right side of their body.
• B. Place the bedside table on the right side of the bed.
• C. Orient the client to the food on their plate using the clock method.
• D. Place the wheelchair on the client's left side.

Correct answer: B

Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.

4. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

5. A client is receiving discharge instructions from a healthcare provider after being prescribed albuterol for COPD. Which statement by the client indicates understanding of the teaching?

• A. Albuterol can increase my blood sugar levels.
• B. Albuterol can decrease my immune response.
• C. I can experience an increase in my heart rate while taking albuterol.
• D. I may develop mouth sores while taking albuterol.

Correct answer: C

Rationale: Albuterol is a bronchodilator commonly used to treat conditions like COPD. One of its common side effects is an increase in heart rate (tachycardia) due to its action on beta-2 receptors in the body. This statement by the client demonstrates an understanding of a potential side effect of albuterol, indicating comprehension of the discharge teaching provided by the healthcare provider.

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