Nokea
The nurse knows that hemolytic to blood transfusions occur most often when the first milliliters of the infusion.
- A. 125
- B. 50
- C. 100
- D. 75
Correct Answer: B
Rationale: Hemolytic reactions strike early 50 mL often triggers as mismatched blood clashes, a rapid antigen-antibody storm. Later volumes (75-125) build on it; 100's common but not peak. Nurses watch those first drops, stopping at 50 mL's hint of fever or pain, a tight window in this transfusion trap.
You may also like to solve these questions
The best way to prevent chronic complications of diabetes is to:
- A. Take medications as prescribed and remove sugar from the diet completely.
- B. Check feet daily for cuts, long toe nails and infections between the toes.
- C. Maintain a BGL that is as close to normal as possible.
- D. Undertake daily exercise to burn up the excess glucose in the system.
Correct Answer: C
Rationale: Preventing diabetes complications (e.g., neuropathy, retinopathy) hinges on glycemic control. Medications and sugar elimination help, but total sugar removal is impractical carbohydrates are broader, and control, not absence, matters. Daily foot checks prevent ulcers but address consequences, not root causes. Maintaining blood glucose levels (BGL) near normal (e.g., HbA1c <7%) via diet, exercise, and drugs prevents microvascular (kidney, eye) and macrovascular (heart) damage, per ADA guidelines. Exercise burns glucose, aiding control, but isn't singularly best' it's part of a triad. Tight BGL management reduces oxidative stress, glycation, and vascular injury, evidenced by trials (e.g., DCCT), making it the cornerstone strategy over isolated tactics, ensuring long-term organ protection.
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?
- A. Cognitive deficits
- B. Impaired wound healing
- C. Cardiac tamponade
- D. Tumor lysis syndrome
Correct Answer: B
Rationale: Radiation pre-surgery zaps tissue impaired wound healing's the big risk, as it fries skin and vessels, slowing repair post-op. Cognitive deficits need brain radiation, not specified. Tamponade's rare, tied to chest radiation and fluid buildup. TLS hits post-chemo, not pre-surgery. Nurses in oncology lock onto skin checks and infection signs, knowing radiation's legacy can tank surgical outcomes if ignored.
You are monitoring your client who is at risk for spinal cord compression related to tumor growth. Which client statement is most likely to suggest early manifestation?
- A. Last night my back really hurt, and I had trouble sleeping
- B. My leg has been giving out when I try to stand
- C. My bowels are just not moving like they usually do
- D. When I try to pass my urine, I have difficulty starting the stream
Correct Answer: A
Rationale: Spinal cord compression from tumors strikes early with back pain reported in 95% of cases as vertebral pressure or nerve irritation flares, a red flag needing urgent imaging to prevent paralysis. Leg weakness signals motor loss, a later sign as compression worsens. Bowel or bladder issues like constipation or hesitancy mark advanced nerve involvement, not initial hints. Nurses prioritize this pain statement, recognizing its prevalence and timing, prompting swift action like steroids or surgery to halt progression, critical in cancer clients where spinal integrity dictates mobility and survival.
Autonomic neuropathies affecting people with chronic diabetes affect many body systems. Which of the following is not a clinical manifestation of this problem?
- A. Tachycardia
- B. Mental confusion
- C. Urinary retention
- D. Anhidrosis
Correct Answer: B
Rationale: Diabetes' nerve mess fast heart, pee stalls, no sweat autonomic signs. Confusion's brain sugar or stroke, not this. Nurses clock these, a chronic nerve quirk.
Which of the following nursing interventions would be appropriate for a client with sickle cell disease?
- A. Prepare the client for surgery
- B. Encourage fluid intake
- C. Provide a warm environment
- D. Keep the client strictly NPO
Correct Answer: B
Rationale: Sickle cell's sticky cells crave hydration fluids thin blood, easing vaso-occlusion, a top intervention to cut crisis. Surgery's rare, warmth helps pain, NPO starves. Nurses push intake, preventing sickling, a hydration win in this hemoglobin war.