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A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.
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A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?
- A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Administer intravenous fluid bolus as prescribed by the healthcare provider.
Correct Answer: A
Rationale: Applying oxygen addresses potential hypoxia or respiratory distress indicated by the elevated vital signs.
An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take?
- A. Check fingerstick glucose level.
- B. Assess skin temperature and moisture.
- C. Administer a PRN dose of regular insulin.
- D. Document anxiety on the surgical checklist.
- E. Measure pulse and blood pressure.
Correct Answer: A,B,E
Rationale: Checking fingerstick glucose, assessing skin temperature/moisture, and measuring pulse/blood pressure are critical to evaluate for hypoglycemia, a likely cause of weakness and jitteriness in a diabetic patient.
The healthcare provider prescribes diagnostic tests for a patient whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse prepare the patient for?
- A. Computerized tomography (CT) of the chest.
- B. Arterial blood gases (ABG).
- C. Sputum culture and sensitivity.
- D. Blood cultures.
Correct Answer: C
Rationale: A sputum culture and sensitivity test identifies the causative organism of pneumonia, guiding appropriate antibiotic therapy.
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan?
- A. Eat a diet that is high in protein and vitamins A and C.
- B. Maintain bed rest as much as possible.
- C. Keep legs elevated when sitting or lying down.
- D. Inspect ankles daily for areas of darkening skin.
- E. Apply intermittent cold compresses four times daily.
Correct Answer: A,C,D
Rationale: A high-protein diet with vitamins A and C, leg elevation, and daily ankle inspections promote healing and monitor complications in venous leg ulcers.
The nurse is assessing a patient's understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?
- A. The patient exclusively consumes lactose-free dairy products.
- B. The patient meticulously cleans and peels all fresh fruits and vegetables.
- C. The patient enjoys fat-free yogurt as an occasional snack.
- D. The patient has eliminated grains from their diet.
Correct Answer: C
Rationale: Consuming fat-free yogurt aligns with the DASH diet's emphasis on low-fat dairy, supporting blood pressure control.