Nokea
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
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The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
The nurse is bathing a client who has contact isolation ordered. The nurse wears gloves. What else is needed?
- A. Face mask
- B. Sterile gloves
- C. Isolation cap
- D. Isolation gown
Correct Answer: D
Rationale: An isolation gown prevents contact transmission, required alongside gloves for bathing a client in contact isolation.
The nurse is caring for a client with a history of deep vein thrombosis.
- A. Which intervention is most important for a client with a deep vein thrombosis?
- B. Administer analgesics for pain relief.
- C. Apply warm, moist compresses to the leg.
- D. Encourage active range-of-motion exercises.
- E. Maintain bed rest with leg elevation.
Correct Answer: D
Rationale: Bed rest with leg elevation reduces venous pressure and prevents clot dislodgement in DVT. Analgesics and compresses are supportive, and active exercises risk embolization.
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.