Nokea
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. As soon as the nurse can prepare the client and the administration set
- B. At 1200
- C. At 1300
- D. At 1400
Correct Answer: A
Rationale: The correct answer is A: As soon as the nurse can prepare the client and the administration set. It is important to start the infusion promptly to maximize the effectiveness of the blood transfusion. Delaying the infusion can lead to potential complications. Options B, C, and D are incorrect because they suggest delayed start times, which can be detrimental to the patient's health. Starting the infusion as soon as possible ensures that the patient receives the necessary blood components in a timely manner.
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A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
- A. Poor
- B. Favorable
- C. Uncertain
- D. Excellent
Correct Answer: A
Rationale: The correct answer is A: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs, resulting in a poor prognosis. The aggressive treatments may help manage symptoms and prolong survival but the overall prognosis remains poor due to the advanced stage of the cancer. Choice B (Favorable) is incorrect because stage IV ovarian cancer has a poor prognosis. Choice C (Uncertain) is incorrect as the prognosis for stage IV ovarian cancer is generally known to be poor. Choice D (Excellent) is incorrect as stage IV ovarian cancer is not associated with an excellent prognosis due to its advanced stage.
A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will be sure to take the albuterol before taking the cromolyn.
- B. I will take both medications at the same time.
- C. I will take the cromolyn before taking albuterol.
- D. I will take the medications in any order.
Correct Answer: A
Rationale: The correct answer is A: "I will be sure to take the albuterol before taking the cromolyn." This is because albuterol is a bronchodilator that helps to open up the airways quickly, providing immediate relief during an asthma attack. Cromolyn, on the other hand, is a mast cell stabilizer that helps to prevent asthma attacks but does not provide immediate relief. Taking albuterol first allows for quick relief, followed by cromolyn for long-term prevention.
Choice B is incorrect as taking both medications at the same time may not allow for the full effectiveness of each drug. Choice C is incorrect as cromolyn should be taken before albuterol to allow time for it to take effect. Choice D is incorrect as there is a specific order in which these medications should be taken for optimal results.
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water-seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Absence of bubbling in the water seal chamber
- D. No drainage in the collection chamber
Correct Answer: A
Rationale: Fluctuation (tidaling) in the water-seal chamber during inspiration and expiration indicates the chest tube is functioning properly.