Nokea
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
- A. Keep the blood refrigerated on the nursing unit until ready to administer.
- B. Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
- C. Do not infuse blood that has been hanging for more than 6 hours.
- D. Administer the blood quickly to prevent wasting it if the client develops a fever.
Correct Answer: B
Rationale: Staying with the client for the first 15 minutes is critical to monitor for acute transfusion reactions, which are most likely to occur early.
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The first thing that you should do immediately after a client accident is to:
- A. Notify the doctor.
- B. Render care.
- C. Assess the client.
- D. Notify the nurse manager.
Correct Answer: C
Rationale: The first action after a client accident is to assess the client to determine the extent of injury and immediate needs, following the nursing process.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
The nurse is assessing a client with suspected dehydration. Which finding supports this diagnosis?
- A. Bounding pulse.
- B. Dry mucous membranes.
- C. Hypertension.
- D. Increased urine output.
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume in the body.
You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n):
- A. Increased creatinine clearance.
- B. Impaired immune system.
- C. Decreased hepatic metabolism.
- D. Increased bodily fat.
Correct Answer: C
Rationale: Elderly individuals often have decreased hepatic metabolism due to reduced liver function, which affects drug metabolism and increases the risk of side effects, adverse reactions, and toxicity.
Which of the following is a risk factor for toxic shock syndrome (TSS)?
- A. Changing tampons every 3 hours.
- B. Avoiding use of deodorized tampons.
- C. Alternating tampons with sanitary pads.
- D. Using only tampons at night.
Correct Answer: D
Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.