Nokea
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
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A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
Which of the following hospitalized clients is at risk to develop parotitis?
- A. A 50-year-old client with nausea and vomiting who is on nothing-by-mouth status.
- B. A 75-year-old client with diabetes who has ill-fitting dentures.
- C. An 80-year-old client who has poor oral hygiene and is dehydrated.
- D. A 65-year-old client with lung cancer who has a feeding tube in place.
Correct Answer: C
Rationale: Dehydration and poor oral hygiene in the 80-year-old client increase the risk of parotitis due to reduced saliva production and bacterial overgrowth.
The nurse is caring for a client in the emergency department who has overdosed on morphine. Which medication does the nurse anticipate to be ordered to reverse the effects of morphine?
- A. sodium bicarbonate
- B. flumazenil
- C. diphenhydramine
- D. naloxone
Correct Answer: D
Rationale: Naloxone is an opioid antagonist used to reverse morphine overdose effects, such as respiratory depression.
A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for:
- A. Footdrop.
- B. Knee swelling and pain.
- C. Tingling in the arm.
- D. Absence of the Achilles reflex.
Correct Answer: C
Rationale: Thoracoscopy positioning (lateral decubitus) can compress nerves in the arm, causing tingling due to brachial plexus injury. Footdrop or Achilles reflex issues are unrelated to this position.
What should the nurse include in the care plan for a client with dysphagia?
- A. Offer thin liquids.
- B. Use a chin-tuck maneuver.
- C. Provide a low-fiber diet.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: The chin-tuck maneuver reduces aspiration risk in clients with dysphagia.