Nokea
A client receiving a blood transfusion develops a fever. What action should the nurse take?
- A. Stop the transfusion immediately.
- B. Administer an antihistamine as prescribed.
- C. Administer a diuretic as prescribed.
- D. Increase the transfusion rate.
Correct Answer: A
Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.
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What is the primary action when caring for a patient with a stage 3 pressure ulcer?
- A. Apply a hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Apply moist gauze to the ulcer
Correct Answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.
A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?
- A. Serum calcium level
- B. Platelet count
- C. INR
- D. WBC count
Correct Answer: C
Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.
A nurse is reviewing the prescription for doxazosin with a client. Which of the following should be included in the teaching?
- A. Decrease caloric intake to prevent weight gain.
- B. Increase dietary fiber to alleviate constipation.
- C. Rise slowly when sitting up from bed.
- D. Take this medication in the morning.
Correct Answer: C
Rationale: The correct answer is C. Doxazosin can cause orthostatic hypotension, leading to dizziness and falls if the client rises quickly from a seated position. Instructing the client to rise slowly when sitting up from bed helps prevent these adverse effects. Choices A, B, and D are incorrect because doxazosin does not directly relate to caloric intake, dietary fiber, or a specific time of day for administration.
Which electrolyte imbalance is most concerning for a patient on loop diuretics?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is hypokalemia. Loop diuretics can cause potassium depletion leading to hypokalemia, which is particularly concerning as it can result in cardiac arrhythmias. Hyponatremia (choice B) is not typically associated with loop diuretics. Hyperkalemia (choice C) is less common in patients on loop diuretics. Hypercalcemia (choice D) is not a typical electrolyte imbalance associated with loop diuretics.
A healthcare professional is preparing to administer enoxaparin to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication intramuscularly.
- B. Inject the medication into the lateral abdominal wall.
- C. Massage the injection site after administration.
- D. Discard the prefilled syringe after expelling the air bubble.
Correct Answer: B
Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.