Nokea
A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
- A. Administer prescribed antihistamine and aspirin.
- B. Collect blood and urine samples and send to the lab.
- C. Administer prescribed diuretics.
- D. Administer prescribed vasopressors.
Correct Answer: B
Rationale: Low back pain and pruritus after 25 mL of PRBCs suggest a transfusion reaction, likely hemolytic or allergic. After stopping the infusion, the nurse should collect blood and urine samples to assess for hemolysis (e.g., free hemoglobin in plasma or urine). Antihistamines may be administered later for allergic symptoms, but lab samples are the priority. Diuretics and vasopressors are not indicated.
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A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.
An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. Which of the following nursing diagnoses will guide the discharge teaching? Select all that apply.
- A. Ineffective tissue perfusion related to decreased cardiac output.
- B. Impaired skin integrity related to barrier changes of the skin.
- C. Risk for injury related to environmental hazards.
- D. Impaired verbal communication related to dysarthria.
- E. Security intolerance related to painful lower extremity.
Correct Answer: B,C
Rationale: Cellulitis causes impaired skin integrity due to infection and inflammation. Parkinson's increases fall risk, supporting risk for injury. Other options are less directly related.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
After a laminectomy, the client states, 'The physician said that I can do anything I want to.' Which of the following client-stated activities indicates the need for further teaching?
- A. Drying the dishes.
- B. Sitting outside on firm cushions.
- C. Making the bed walking from side to side.
- D. Sweeping the front porch.
Correct Answer: D
Rationale: Sweeping involves twisting and bending, which can strain the surgical site post-laminectomy.
The nurse notes a client's preoperative hemoglobin is 9.8 g/dL. What is the priority nursing action?
- A. Administer iron supplements as ordered.
- B. Notify the surgeon of the result.
- C. Encourage a high-protein diet.
- D. Document the finding and continue preparations.
Correct Answer: B
Rationale: A hemoglobin of 9.8 g/dL indicates anemia, which increases surgical risks. Notifying the surgeon ensures evaluation and possible intervention before proceeding.