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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 signify a severe ABO incompatibility reaction, necessitating urgent reporting to prevent life-threatening complications such as renal failure or disseminated intravascular coagulation.
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The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
- A. Brown, rough, greasy, wart-like papules on the face.
- B. Thick skin plaques topped by silvery white scales.
- C. Requires sunglasses because sunlight hurts eyes.
- D. Tenderness upon palpation and generalized erythema.
Correct Answer: D
Rationale: Tenderness and generalized erythema indicate overexposure to PUVA, signaling potential burns or excessive UV exposure.
A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse's priority intervention?
- A. Obtain a sputum sample.
- B. Arrange transport for radiographic imaging.
- C. Move the patient into airborne isolation.
- D. Collect specimens for blood cultures.
Correct Answer: C
Rationale: Symptoms suggestive of tuberculosis require immediate airborne isolation to prevent transmission.
The healthcare provider prescribes penicillin 200,000 units intramuscularly for a patient with pneumonia. The available vial is labeled 'Penicillin 500,000 units/mL'. How much penicillin should be administered to the patient?
- A. 0.2 mL
- B. 0.4 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: B
Rationale: Dividing the prescribed dose (200,000 units) by the concentration (500,000 units/mL) yields 0.4 mL, the correct volume to administer.
While assessing a patient with degenerative joint disease, the nurse notices Heberden's nodes, and large prominences on the patient's fingers that are reddened and painful. What should the nurse do?
- A. Discuss strategies for managing chronic pain with the patient.
- B. Check the patient's radial pulses and capillary refill time.
- C. Immediately notify the healthcare provider of the finding.
- D. Review the patient's dietary intake of high-protein foods.
Correct Answer: A
Rationale: Discussing chronic pain management strategies addresses the discomfort associated with Heberden's nodes, a common osteoarthritis feature.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Crohn's disease with colectomy.
- C. History of nephrotic syndrome.
- D. Type 2 diabetes mellitus.
Correct Answer: B
Rationale: Crohn's disease with colectomy creates peritoneal adhesions, making peritoneal dialysis unsuitable.