Nokea
A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following?
- A. Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient.
- B. Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion.
- C. Febrile reactions are rarely immune-mediated and can be a sign of hemolytic transfusion.
- D. Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.
Correct Answer: B
Rationale: Febrile reactions can often be prevented with premedication like antipyretics and antihistamines, which is a reassuring and accurate response for the client.
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The nurse overhears a surgical team member discussing a client's procedure in the hospital cafeteria. The nurse should:
- A. Report the breach to the hospital's privacy officer.
- B. Confront the team member immediately.
- C. Document the incident in the client's chart.
- D. Ignore the conversation as it was unintentional.
Correct Answer: A
Rationale: Discussing client information in a public area violates HIPAA. Reporting to the privacy officer ensures proper handling of the confidentiality breach.
A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
The nurse administers theophylline (TheoDur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate?
- A. Suppression of the client's respiratory infection.
- B. Decrease in bronchial secretions.
- C. Relaxation of bronchial smooth muscle.
- D. Thinning of tenacious, purulent sputum.
Correct Answer: C
Rationale: Theophylline relaxes bronchial smooth muscle, relieving bronchospasm in COPD. It does not suppress infection, reduce secretions, or thin sputum.
Which symptom suggests bladder cancer recurrence?
- A. Painful urination.
- B. Frequent urination.
- C. Hematuria.
- D. Nocturia.
Correct Answer: C
Rationale: Hematuria is a common sign of bladder cancer recurrence.
Which statement by a client with a new ileal conduit indicates a need for further teaching?
- A. I will empty the pouch when it is one-third full.
- B. I can use vinegar to clean my appliance.
- C. I should drink 2,000 mL of fluid daily.
- D. I will wear tight clothing to hide the pouch.
Correct Answer: D
Rationale: Tight clothing can irritate the stoma and impair appliance function, indicating a misunderstanding of proper care.