Nokea
A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take to infuse?
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: B
Rationale: A unit of packed red blood cells is approximately 250–300 mL. At 60 mL/hour, 240 mL (close to a unit) takes 240 ÷ 60 = 4 hours.
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Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm. Which of the following clients should the nurse prioritize? The client who?
- A. reports numbness and tingling in all their extremities.
- B. has paralysis on both lower extremities.
- C. is confused and cannot remember their name or why they are in the emergency department.
- D. experienced a massive electrical current discharge to their body.
Correct Answer: B
Rationale: Paralysis in both lower extremities indicates potential spinal cord injury or severe neurological damage, requiring immediate prioritization. Numbness and tingling (A) suggest peripheral nerve issues, confusion (C) may indicate concussion or hypoxia, and massive discharge (D) lacks specific clinical urgency without symptoms.
A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client?
- A. Intensity.
- B. Cause.
- C. Aggravating factors.
- D. Location.
Correct Answer: A
Rationale: Pain intensity is the most significant component in assessing bone cancer pain, as it guides the urgency and type of pain management interventions needed.
The client with diabetes mellitus says, 'If I could just avoid what you call carbohydrates in my diet, I guess I would be okay.' The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following?
- A. Carbohydrates only.
- B. Fats and carbohydrates only.
- C. Protein and carbohydrates only.
- D. Proteins, fats, and carbohydrates.
Correct Answer: D
Rationale: Diabetes affects the metabolism of carbohydrates, proteins, and fats due to insulin's role in regulating all three macronutrients.
After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan?
- A. Nutritional intake.
- B. Management of alopecia.
- C. Exercise and activity levels.
- D. Access to community resources.
Correct Answer: A
Rationale: Radiation therapy can affect appetite and digestion, making nutritional intake a priority in the teaching plan to maintain the client's strength and recovery. The other options are less critical.
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.