Nokea
A client has surgery scheduled in 2 weeks. He decides to donate his own blood ahead of time to be stored and used in case he needs a blood transfusion during his surgery. This type of blood donation is referred to as
- A. an allogeneic donation.
- B. an xenogeneic donation.
- C. an autologous donation.
- D. a directed donation.
Correct Answer: C
Rationale: Autologous donation involves donating one’s own blood for personal use during surgery, reducing transfusion risks.
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A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which physician prescription would the nurse question?
- A. D5W at 200 mL/hr
- B. Demeclocycline (Declomycin) 150 mg Q6h
- C. Daily weights
- D. Intake and output Q4h
Correct Answer: A
Rationale: D5W at 200 mL/hr is inappropriate for SIADH, as it can worsen hyponatremia by adding free water. The other options are appropriate for monitoring and treating SIADH.
The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?
- A. Suction the client’s airway.
- B. Notify the respiratory therapist.
- C. Check the ventilator tubing for kinks.
- D. Administer a bronchodilator.
Correct Answer: C
Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms
The nurse is caring for a client with end-stage kidney disease. The client says, 'I have decided that I don't want any more dialysis or treatments. This is just prolonging the inevitable.' The nurse responds, 'You have every right to do so. I will notify the nephrologist of your wishes.' Which ethical principle is being demonstrated by the nurse?
- A. justice
- B. fidelity
- C. autonomy
- D. beneficence
Correct Answer: C
Rationale: Respecting the client’s decision to refuse treatment demonstrates autonomy, prioritizing their right to self-determination.
The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?
- A. Slow the transfusion rate and administer diphenhydramine.
- B. Stop the transfusion and notify the physician.
- C. Increase the transfusion rate to complete it quickly.
- D. Administer acetaminophen for discomfort.
Correct Answer: B
Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority
The physician prescribes captopril (Capoten) 25 mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
- A. Tinnitus
- B. Persistent cough
- C. Muscle weakness
- D. Diarrhea
Correct Answer: B
Rationale: Captopril, an ACE inhibitor, commonly causes a persistent dry cough.