Nokea
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?
- A. Obtain the pre-transfusion hemoglobin level.
- B. Prime the tubing and set up the blood pump.
- C. Monitor vital signs every 15 minutes for the first hour.
- D. Ensure the accuracy of the blood type match.
Correct Answer: D
Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.
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A healthcare professional is reviewing the medical record of a client who has hypocalcemia. The healthcare professional should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?
- A. Crohn's disease
- B. Postoperative status following appendectomy
- C. History of bone cancer
- D. Hyperthyroidism
Correct Answer: A
Rationale: Crohn's disease is known to impair calcium absorption, which can lead to hypocalcemia. This condition affects the intestines and can disrupt the normal absorption of nutrients, including calcium. Postoperative status following appendectomy, history of bone cancer, and hyperthyroidism are typically not directly associated with a higher risk of developing hypocalcemia compared to Crohn's disease.
When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?
- A. Confirm unresponsiveness
- B. Check for a pulse
- C. Begin chest compressions
- D. Call for emergency help
Correct Answer: A
Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.
The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
- A. Place the chair at a right angle to the bed on the client's left side before moving.
- B. Assist the client to a standing position, then place the right hand on the armrest.
- C. Have the client place the left foot next to the chair and pivot to the left before sitting.
- D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Correct Answer: D
Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.
Which of the following manifestations confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.
The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will take my medication at the same time every day.
- C. I will use a soft toothbrush to prevent gum bleeding.
- D. I can take aspirin if I have a headache.
Correct Answer: D
Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.