Nokea
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
- A. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.
- B. Slow the transfusion and monitor the client closely.
- C. Stop the transfusion, notify the blood bank, and administer antihistamines
- D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank
Correct Answer: D
Rationale: In the case of an acute hemolytic reaction during a blood transfusion, the most important nursing intervention is to immediately stop the transfusion and infuse normal saline solution. This is crucial to prevent further complications associated with the hemolysis of red blood cells. Normal saline helps maintain blood pressure and support kidney function, which may be compromised during a hemolytic reaction. Additionally, notifying the blood bank is important to investigate and prevent future reactions, and to determine if there was an error in blood compatibility. Administering antihistamines or changing the fluid type (such as dextrose 5% in water) will not address the underlying issue of hemolysis and may not be the most appropriate interventions in this scenario.
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The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
- A. Has intercourse with just the spouse
- B. Makes a donation of a pint of whole blood
- C. Limits sexual contact to those without HIV antibodies
- D. Uses a'condom each time there is a sexual intercourse
Correct Answer: C
Rationale: The correct answer is C. An individual has no risk of exposure to HIV when they limit sexual contact to those without HIV antibodies. This is because HIV is primarily transmitted through contact with body fluids such as blood, semen, vaginal fluids, and breast milk of an infected person. If an individual only engages in sexual activities with people who do not have HIV antibodies, the risk of exposure to the virus is significantly reduced. It is important to note that although this reduces the risk, it does not completely eliminate it, as there is still a chance of transmission through other means such as sharing needles or from mother to child during pregnancy, childbirth, or breastfeeding.
What is the best method to obtain a urine sample in an 8-month-old being evaluated for a UTI?
- A. Clean the perineum front-to-back and apply a urine collection bag.
- B. Insert an indwelling Foley catheter.
- C. Place a sterile cotton ball in the diaper and collect with a syringe.
- D. Perform an in-and-out (straight) catheterization.
Correct Answer: D
Rationale: For infants who are not toilet-trained, an in-and-out catheterization is the most reliable method for obtaining a sterile urine sample.
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. When adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
- A. Hypertension
- B. Muscle wasting
- C. Osteoporosis
- D. Truncal obesity
Correct Answer: C
Rationale: Osteoporosis is the most likely adverse effect of long-term corticosteroid therapy responsible for the severe back pain experienced by the client with systemic lupus erythematosus (SLE). Corticosteroids such as prednisone can lead to bone resorption and calcium loss, resulting in weakened bones and increased risk of fractures. Back pain in this case could be a sign of vertebral compression fractures due to osteoporosis induced by prolonged corticosteroid use. It is important for healthcare providers to monitor bone health in patients on long-term corticosteroid therapy and consider strategies to prevent or manage osteoporosis.
When a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as:
- A. uremia.
- B. oliguria.
- C. proteinuria.
- D. pyelonephritis.
Correct Answer: A
Rationale: Chronic renal failure leads to the build-up of waste products and toxins in the blood, known as uremia. This condition results from the kidneys' inability to effectively filter waste from the blood and maintain proper fluid and electrolyte balance. As renal function declines, uremia can lead to a variety of clinical manifestations such as fatigue, nausea, itching, and electrolyte imbalances, ultimately resulting in the clinical syndrome known as uremia. Oliguria refers to reduced urine output, proteinuria is the presence of excessive protein in the urine, and pyelonephritis is a bacterial infection of the kidneys - these conditions may be present in chronic renal failure but are not the defining clinical syndrome.
A patient has orders to receive 1 L (1000 mL) of 5% dextrose and lactated Ringer's solution to be infused over 8 hours. How many millilitres will be infused per hour?
- A. 80
- B. 100
- C. 125
- D. 150
Correct Answer: C
Rationale: The total volume to be infused over 8 hours is 1000 mL. To determine how many millilitres will be infused per hour, you can divide the total volume by the total time: