Nokea
A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications?
- A. Anaphylactic reaction.
- B. Circulatory overload.
- C. Sepsis.
- D. Acute hemolytic reaction.
Correct Answer: B
Rationale: Difficulty breathing, elevated blood pressure, and cough suggest circulatory overload, a transfusion complication due to fluid volume excess.
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Which of the following would demonstrate the correct technique for applying an elastic bandage to a leg?
- A. Increase tension with each successive turn of the bandage.
- B. Start at the distal end of the extremity and move toward the trunk.
- C. Secure the bandage with clips over the area of the inner thigh.
- D. Overlap each layer twice when wrapping.
Correct Answer: B
Rationale: Starting at the distal end and moving toward the trunk promotes venous return and prevents constriction.
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?
- A. Vitamin K
- B. Phentolamine
- C. Protamine sulfate
- D. Calcium gluconate
Correct Answer: B
Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Vaginal bleeding.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Vaginal bleeding may indicate endometrial cancer, a serious side effect of tamoxifen, requiring immediate reporting.
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
When suctioning a client's tracheostomy tube, the nurse should incorporate which of the following steps into the procedure?
- A. Oxygenate the client before suctioning.
- B. Insert the suction catheter about 2 inches into the cannula.
- C. Use a bolus of sterile water to stimulate coughing.
- D. Use clean gloves during the procedure.
Correct Answer: A
Rationale: Pre-oxygenation prevents hypoxia during tracheostomy suctioning, ensuring client safety.