Nokea
A client with an ileal conduit should report:
- A. Mucus in urine.
- B. Stoma bleeding.
- C. Yellow urine.
- D. No odor.
Correct Answer: B
Rationale: Stoma bleeding is abnormal and may indicate trauma or infection.
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Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
- A. Assess breath sounds.
- B. Remove the catheter.
- C. Insert a peripheral I.V.
- D. Reposition the client.
Correct Answer: A
Rationale: Restlessness and tachypnea post-catheter insertion suggest a pneumothorax, a complication. Assessing breath sounds detects absent or diminished sounds, guiding intervention. Removing the catheter, inserting an I.V., or repositioning does not address the urgent issue.
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
- A. Awake the client
- B. Check the armband for client identification number and compare with the order
- C. Label the sample vial in front of the client
- D. Verify the room number with the room assignment
- E. Ask the client to state his/her name
Correct Answer: B,C,E
Rationale: Rationales: B) Checking the armband ensures correct client identification, critical for safety. C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity. A) Awakening the client is unnecessary if asleep, as the draw can be done gently. D) Room number is unreliable for identification.
A client with acute renal failure is prescribed a low-potassium diet. Which food should be avoided?
- A. Bananas.
- B. Rice.
- C. Apples.
- D. Bread.
Correct Answer: A
Rationale: Bananas are high in potassium, unsuitable for a low-potassium diet.
Sensorineural hearing loss results from which of the following conditions?
- A. Presence of fluid and cerumen in the external canal.
- B. Sclerosis of the bones of the middle ear.
- C. Change to the cochlear or vestibulocochlear nerve.
- D. Emotional disturbance resulting in a functional hearing loss.
Correct Answer: C
Rationale: Sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve, affecting the inner ear or neural pathways.