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: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.
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A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Administer eye drops immediately.
Correct Answer: C
Rationale: Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.
The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.
What can the nurse instruct the mother of a teething 9-month-old infant to relieve discomfort?
- A. Rub the infant's gums with baby aspirin dissolved in water.
- B. Obtain an over-the-counter (OTC) topical medication for gum pain relief.
- C. Schedule an appointment with a dentist for a dental evaluation.
- D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast.
Correct Answer: D
Rationale: Teething in infants can cause discomfort, but it is a normal process. Symptoms may include nighttime awakening, daytime restlessness, excess drooling, and temporary loss of appetite. The recommended approach to relieve teething discomfort includes providing cool liquids, a Popsicle, or hard foods like dry toast for chewing. These items can help soothe the infant's gums. Rubbing the gums with baby aspirin dissolved in water is not recommended as it can be harmful. OTC topical medications are unnecessary for teething discomfort. Scheduling a dental evaluation is not required solely for teething. It's important to avoid home remedies like baby aspirin and opt for safer options like cool liquids. If necessary, acetaminophen (Tylenol) can be used under healthcare provider guidance to alleviate discomfort.
What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?
- A. Discussing the repetitive actions.
- B. Insisting the client not perform the repetitive act.
- C. Informing the client that the act is not necessary.
- D. Encouraging daily exercise.
Correct Answer: D
Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.
Which of the following services is not typically part of family consultation?
- A. assisting with vocational rehabilitation
- B. providing information about the client's illness
- C. teaching effective communication
- D. helping families solve problems
Correct Answer: A
Rationale: In family consultation, the primary focus is on helping families address their emotions, enhance communication skills, and resolve issues. Assisting with vocational rehabilitation involves a different scope beyond the typical objectives of family consultation. While providing information about the client's illness, teaching effective communication, and aiding families in problem-solving are common in family consultation to promote understanding, healthy dynamics, and conflict resolution.