Nokea
A client is receiving a blood transfusion following surgery. In the event of a transfusion reaction, any unused blood should be:
- A. Sealed and discarded in a red bag
- B. Flushed down the client's commode
- C. Sealed and discarded in the sharp's container
- D. Returned to the blood bank
Correct Answer: D
Rationale: Unused blood must be returned to the blood bank for analysis in case of a transfusion reaction.
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The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?
- A. Rock her to sleep every night until she is in a deep sleep.
- B. Give diphenhydramine 12.5 mg orally to put the baby to sleep.
- C. If she starts waking up a lot in the middle of the night, put her in the bed with you.
- D. Give the last feeding as late as possible, and put her in the bed awake without a bottle.
Correct Answer: D
Rationale: Placing the baby in bed awake after a late feeding promotes self-soothing and healthy sleep habits, unlike the other options, which may create dependencies or safety risks.
An RN is working with an LPN to care for a group of clients. Which client would the RN most likely assign to the LPN?
- A. a client receiving blood following back surgery
- B. a client who has just returned from having a left heart catheterization
- C. a client with an arterial line who is on a nitroprusside drip to control blood pressure
- D. a client with an abdominal wound requiring dressing changes every 4 hours and PRN
Correct Answer: D
Rationale: The client requiring dressing changes is stable and within the LPN's scope of practice, whereas the other clients require advanced monitoring or interventions suitable for an RN.
The nurse is assessing a newborn 24 hours after birth. Which of the following findings would require further evaluation?
- A. Heart rate of 140 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Presence of milia on the nose.
- D. Caput succedaneum crossing the suture line.
Correct Answer: C
Rationale: milia are normal, but persistent or widespread milia may indicate other issues; other findings are within normal limits for a newborn
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.
The nurse recognizes which of the following as a Category A biological agent that may be used in terroristic acts?
- A. typhoid
- B. smallpox
- C. malaria
- D. Ebola
Correct Answer: B
Rationale: Smallpox is a Category A bioterrorism agent due to its high mortality and transmissibility. Others are Category B or C.