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A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse’s first best action?
- A. Report the signs and symptoms to the
- B. Monitor the client’s vital signs
- C. Assess respiratory status
- D. Stop the infusion
Correct Answer: D
Rationale: The correct answer is D: Stop the infusion. This is the best action because the client is likely experiencing a transfusion reaction. Stopping the infusion immediately is crucial to prevent further complications. Reporting the signs and symptoms to the healthcare provider (A) can cause a delay in addressing the reaction. While monitoring vital signs (B) and assessing respiratory status (C) are important, stopping the infusion takes precedence to ensure the client's safety and prevent a severe reaction.
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The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A because signs and symptoms listed are indicative of disseminated intravascular coagulation (DIC), which is a serious condition where blood clotting and bleeding occur simultaneously. Change in level of consciousness can indicate hypoperfusion from clotting in blood vessels. Tachypnea and tachycardia can result from tissue hypoxia. Petechiae are small red or purple spots on the skin due to bleeding under the skin.
Choices B, C, and D are incorrect because they do not align with the typical signs and symptoms of DIC. Choice B suggests a possible myocardial infarction or acute coronary syndrome. Choice C indicates a possible thrombotic thrombocytopenic purpura (TTP) or acute limb ischemia. Choice D suggests a mix of symptoms that do not typically present together in DIC.
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
- A. Administer pain medication every 4 hours as needed.
- B. Turn the patient every 2 hours, even hours. NursingStoreRN
- C. Monitor vital signs, especially rhythm.
- D. Keep the bed side rails up at all times.
Correct Answer: B
Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.
Which of the following risk factors presents the greatest threat for respiratory disease?
- A. Smoking
- B. Exposure to radiation
- C. High-fat diet
- D. Alcohol consumption
Correct Answer: A
Rationale: The correct answer is A: Smoking. Smoking presents the greatest threat for respiratory disease due to the harmful chemicals in tobacco that can damage the lungs and lead to conditions like COPD and lung cancer. Smoking is a well-known risk factor for various respiratory issues. Exposure to radiation (B) can increase cancer risk but is not as directly linked to respiratory diseases. High-fat diet (C) may impact overall health but is not a primary risk factor for respiratory diseases. Alcohol consumption (D) can contribute to respiratory issues, but smoking is considered the most significant risk factor.
Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.
Which of the ff. conditions places a patient at risk for respiratory complications following his splenectomy?
- A. A low platelet count
- B. Early ambulation
- C. An incision near the diaphragm
- D. Early discharge
Correct Answer: C
Rationale: The correct answer is C: An incision near the diaphragm. Following a splenectomy, an incision near the diaphragm can lead to respiratory complications due to potential irritation or injury to the diaphragm. This can result in impaired breathing and increased risk of respiratory issues such as pneumonia.
A: A low platelet count is not directly related to respiratory complications following a splenectomy.
B: Early ambulation is generally encouraged to prevent complications such as blood clots but does not specifically impact respiratory complications.
D: Early discharge may not directly lead to respiratory complications, as long as the patient is adequately monitored postoperatively.