A nurse at a community health clinic is caring for a patient who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Check the patient's blood temperature.

Administer an oral analgesic.

Perform a complete blood count.

Evaluate the patient's neurological status.

Answer and Explanation

The Correct Answer is A

A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.

B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).

C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.

D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.

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Correct Answer is C

Explanation

A. Milk and turkey slices. – Incorrect. Milk can inhibit iron absorption, and turkey is not a rich source of iron.

B. Fish and cottage cheese. – Incorrect. Cottage cheese is low in iron, and while some fish contain iron, they are not the best sources.

C. Spinach and beef. – Correct Answer. Both are excellent sources of iron, which helps improve hemoglobin levels in iron-deficiency anemia.

D. Yogurt and mozzarella. – Incorrect. Dairy products do not provide significant iron and may inhibit its absorption.

A. 8 hr B. 6 hr C. 4 hr D. 2 hr

Correct Answer is C

Explanation

A. 8 hr – Incorrect. RBC transfusions must not exceed 4 hours due to the risk of bacterial growth and hemolysis.

B. 6 hr – Incorrect. Blood products should be infused within a maximum of 4 hours to prevent complications.

C. 4 hr – Correct Answer. The maximum infusion time for packed RBCs is 4 hours to reduce the risk of bacterial contamination and infection.

D. 2 hr – Incorrect. While blood is often infused within 2 hours, the maximum safe limit is 4 hours.

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A nurse at a community health clinic is caring for a patient who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Nursing Test Bank

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