Nokea
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
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A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should:
- A. Encourage the client to gargle with oral lidocaine to decrease throat irritation.
- B. Monitor the client for signs of pneumothorax.
- C. Administer pain medication as needed to relieve mediastinal discomfort.
- D. Advise the client not to talk until the gag reflex returns.
Correct Answer: B
Rationale: Monitoring for pneumothorax is critical after a bronchoscopy with biopsy, as it is a potential complication due to lung puncture.
A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?
- A. Breast-feed only with the unaffected breast.
- B. Stop breast-feeding because you probably have an infection.
- C. Notify your health care provider because you may need medication.
- D. Continue breast-feeding since this is a normal response in breast-feeding mothers.
Correct Answer: C
Rationale: Based on the signs and symptoms presented by the client (particularly the elevated temperature), the primary health care provider needs to be notified because an antibiotic that is tolerated by the infant, as well as the mother, may be prescribed. The mother should continue to nurse on both breasts, but should start the infant on the unaffected breast while the affected breast lets down.
The nurse is conducting a prostate screening clinic. Which sign of prostatism should the nurse question each client about?
- A. Absence of postvoid dribbling
- B. Ability to stop voiding quickly
- C. Excessive force in urinary stream
- D. Hesitancy when initiating urinary stream
Correct Answer: D
Rationale: Signs of prostatism that may be reported to the nurse are reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating quickly, a sensation of incomplete bladder emptying after voiding, and an increase in episodes of nocturia. These symptoms are the result of pressure of the enlarging prostate on the client's urethra.
A client with a diagnosis of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Etanercept, a TNF inhibitor, increases the risk of infections due to immune suppression.
A client with a history of chronic lymphocytic leukemia is prescribed rituximab (Rituxan). The nurse should monitor the client for which of the following side effects during infusion?
- A. Hypotension.
- B. Hyperglycemia.
- C. Infusion reactions.
- D. Weight loss.
Correct Answer: C
Rationale: Rituximab can cause infusion reactions, such as fever or chills, requiring close monitoring during administration.