Nokea
A client undergoing a mastectomy asks why she needs to sign a blood transfusion consent form. The nurse's best response is:
- A. œIt's a precaution in case of excessive bleeding during surgery.'
- B. œAll surgical clients must sign this form.'
- C. œIt ensures you receive blood if you request it.'
- D. œIt's required to test your blood type before surgery.'
Correct Answer: A
Rationale: Explaining that the consent is a precaution for potential bleeding addresses the client's question accurately and promotes informed consent.
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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?
- A. Rectal temperature
- B. Generalized shivering
- C. Urine output
- D. Assessment of the peripheral pulses
- E. Client reports of thirst
Correct Answer: B,C
Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (A), pulses (D), and thirst (E) are expected or less urgent.
During the preoperative interview, the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client?
- A. Current use of medications, herbs, and vitamins.
- B. Over-the-counter medication use in the last 6 weeks.
- C. Steroid use in the last year.
- D. Use of all drugs taken in the last 18 months.
Correct Answer: D
Rationale: Recording all drugs taken in the last 18 months is excessive, as many may no longer be relevant to surgical risks. Current medications, recent over-the-counter drugs, and steroid use are critical due to their potential impact on surgery.
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
- A. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity.
- B. Notify the physician of the amount of chest tube drainage.
- C. Add water to maintain the water seal.
- D. Lower the drainage system to maintain gravity flow.
Correct Answer: D
Rationale: To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.
A client with leukemia is admitted with a white blood cell count of 2,000/mm³ and a fever of 101.8°F (38.8°C). The nurse should initiate:
- A. Contact precautions.
- B. Reverse isolation.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: B
Rationale: A low white blood cell count (2,000/mm³) with fever indicates neutropenia and high infection risk, necessitating reverse isolation to protect the client from pathogens.
Which of the following variables is most important to assess when determining the impact of the cancer diagnosis and treatment modalities on a long-term survivor's quality of life?
- A. Occupation and employability.
- B. Functional status.
- C. Evidence of disease.
- D. Individual values and beliefs.
Correct Answer: B
Rationale: Functional status, including physical and emotional capabilities, is the most important variable affecting a long-term cancer survivor's quality of life, as it reflects their ability to engage in daily activities.