Nokea
A client is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client develops a fever and chills. Which of the following actions should the nurse take FIRST?
- A. Stop the transfusion immediately.
- B. Notify the physician.
- C. Administer acetaminophen.
- D. Increase the infusion rate.
Correct Answer: A
Rationale: fever and chills may indicate a transfusion reaction, and the transfusion must be stopped immediately
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A 50-year old man who attends an outpatient clinic is taking chlorpromazine hydrochloride (Thorazine) 100 mg tid. He reports to the nurse that he is sleeping through the day.
What should the nurse do?
- A. Contact the physician to change the dose to 100 mg bid.
- B. Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs.
- C. Instruct the man to take frequent naps during the day.
- D. Encourage the man to be more active during the day.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) 300-400 mg/day is needed to treat psychosis (2) correct-will reduce daytime sedation (3) won't decrease sedation from medication (4) won't decrease sedation from medication
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have pain in my upper abdomen.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Upper abdominal pain may indicate pancreatitis, a rare but serious side effect of sitagliptin, requiring immediate evaluation. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with breakfast is acceptable.
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
- A. Turn the client every two hours to the unaffected side.
- B. Maintain the client in a supine position.
- C. Encourage the client to use a bedside commode.
- D. Placing a footboard on the bed.
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side
The nurse is caring for a 34-year-old man admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders?
- A. Ketorolac tromethamine (Toradol).
- B. Codeine phosphate (Paveral).
- C. Oxycodone terephthalate (Percodan).
- D. Hydromorphone hydrochloride (Dilaudid).
Correct Answer: C
Rationale: contraindicated for persons with bleeding disorders, contains aspirin
The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus?
- A. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
- B. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
- C. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily.
- D. A 22-year-old leukemic client with a platelet count of 120,000/mm³ and a hemoglobin level of 9.0 g.
Correct Answer: B
Rationale: obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli