A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
- A. Bleeding time
- B. Hemoglobin and hematocrit
- C. White blood cells
- D. Platelets
Correct Answer: B
Rationale: Hemoglobin and hematocrit. The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.
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When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. relaxation and sleep
- B. deep breathing and coughing
- C. incisional healing
- D. range of motion exercises
Correct Answer: B
Rationale: The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management.
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
- A. Offering the client sterile disposable tissues
- B. Wearing a mask while examining the client
- C. Offering the client water to drink while waiting
- D. Teaching how to cover the mouth when coughing
- E. Performing hand hygiene before and after client contact
- F. Separating the client by at least 3 feet from others in the area
Correct Answer: B,D,E,F
Rationale: B: A mask is required during examination to prevent droplet transmission. D: Teaching cough etiquette reduces spread. E: Hand hygiene prevents pathogen transmission. F: Maintaining 3 feet distance reduces droplet spread. A: Sterile tissues are unnecessary. C: Water does not limit transmission.
A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?
- A. The client complains of a salty taste in the mouth when the dye is injected.'
- B. The client's entire body turns a bright red color.'
- C. The client states 'I have a feeling of getting warm.''
- D. The client gags and complains 'I am getting sick.''
Correct Answer: B
Rationale: The client's entire body turns a bright red color.' This observation suggests anaphylaxis which results in massive vasodilation. Other findings would be immediate wheezing and/or respiratory arrest.