Nokea
A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. Packed red blood cells
- B. Platelets
- C. Plasma
- D. Granulocytes
Correct Answer: A
Rationale: Packed red blood cells require cross-matching due to their antigens and antibodies, unlike platelets, plasma, or granulocytes, which do not contain red cells.
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When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
- A. Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.'
- B. If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age.'
- C. When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch.'
- D. You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time.'
Correct Answer: A
Rationale: To provide the best response, the nurse must identify what the elder is asking. Concern is being expressed about whether elders can engage in sexual activity. The most therapeutic response by the nurse is Choice 1. In this choice, the nurse acknowledges that elders can physically engage in sexual activity and have no psychological barriers to the same. All of the other choices contain facts but are not the best initial response. Choice 1 opens the conversation for the expression of further concerns about sexual issues.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct Answer: C
Rationale: All of the strategies listed are included in home care for the client with Cushing's syndrome. Choice 3 is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function. Choice 1 might enhance body image because it prevents falls that could cause further injury and debilitation. Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.
Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to:
- A. supplement vitamin pills.
- B. balance body molecules.
- C. cure many diseases.
- D. help improve body defenses.
Correct Answer: D
Rationale: Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: Normal saline (0.9% sodium chloride) is isotonic and safe for flushing IV lines before and after blood administration, preventing cell lysis or clotting.
Who should receive the hepatitis A vaccine?
- A. children who are 18 months of age
- B. infants, who should receive the vaccination at birth
- C. people who travel to other countries
- D. individuals who might come into contact with blood
Correct Answer: C
Rationale: Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.