Nokea
A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?
- A. Continue the transfusion at a slower rate
- B. Administer an antipyretic
- C. Stop the transfusion immediately
- D. Notify the healthcare provider
Correct Answer: C
Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.
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A client is prescribed warfarin (Coumadin) for atrial fibrillation. Which dietary instruction should the nurse provide?
- A. Increase intake of green leafy vegetables
- B. Avoid foods high in vitamin K
- C. Increase intake of foods rich in vitamin C
- D. Limit intake of dairy products
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Vitamin K can decrease the effectiveness of warfarin, so it is essential for clients on warfarin therapy to avoid foods high in vitamin K. Green leafy vegetables are high in vitamin K, so choice A is incorrect. Choices C and D are unrelated to the dietary restrictions needed for clients taking warfarin and are therefore incorrect.
Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who
- A. is immobile on prescribed bedrest.
- B. has pressure ulcers on several toes.
- C. has diminished pedal pulse volume.
- D. is confused and trying to climb out of bed.
Correct Answer: A
Rationale: The correct answer is A. Pneumatic compression devices are most beneficial for immobile clients on prescribed bedrest to prevent deep vein thrombosis. Applying these devices helps in promoting circulation and preventing blood clots. Choices B, C, and D do not specifically relate to the primary indication for pneumatic compression devices, making them incorrect. Pressure ulcers, diminished pedal pulse volume, and confusion with climbing out of bed may require different interventions or treatments.
The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?
- A. Restrict sodium intake
- B. Encourage high-protein meals
- C. Increase fluid intake
- D. Administer diuretics as prescribed
Correct Answer: D
Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.
The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?
- A. Duodenum
- B. Gastric pylorus
- C. Liver
- D. Spleen
Correct Answer: C
Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
- A. Temperature of 100.8°F
- B. A pulse rate of 150 beats per minute
- C. A respiratory rate of 10 breaths per minute
- D. A blood pressure of 180/110
Correct Answer: C
Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.