Nokea
A client with severe anemia is to receive a unit of whole blood. In the event of a transfusion reaction, the first action by the nurse should be to:
- A. Notify the physician and the nursing supervisor
- B. Stop the transfusion and maintain an IV of normal saline
- C. Call the lab for verification of type and cross match
- D. Prepare an injection of Benadryl (diphenhydramine)
Correct Answer: B
Rationale: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.
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During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse's first action should be to:
- A. Notify the hospital pharmacist
- B. Notify the nursing supervisor
- C. Notify the Board of Nursing
- D. Notify the director of nursing
Correct Answer: B
Rationale: A narcotic discrepancy requires reporting to the supervisor for investigation.
Which of the following is a core measure set developed by the Joint Commission?
- A. genetics
- B. lymphoma
- C. nosocomial infections
- D. heart failure
Correct Answer: D
Rationale: Heart failure is a Joint Commission core measure set, focusing on improving care quality for common conditions. The others are not core measures.
The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- A. Optimal restoration of the client's elimination pattern
- B. Restoration of the client's neurosensory function
- C. Prevention of complications from impaired elimination
- D. Promotion of a positive body image
Correct Answer: C
Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.
An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
- A. .45 normal saline
- B. Dextrose 1% in water
- C. Lactated Ringer's
- D. Dextrose 5% in .45 normal saline
Correct Answer: C
Rationale: Lactated Ringer's is isotonic and effective for correcting dehydration in obstetric clients, replacing fluids and electrolytes.
The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
- A. Third-degree burns to the face and neck area, with singed nasal hairs
- B. Second-degree burns to each leg and thigh area, who is alert and oriented
- C. A chemical burn that has been removed and liberally flushed before admission
- D. An electrical burn entering and leaving on the same side of the body
Correct Answer: A
Rationale: Third-degree burns to the face and neck with singed nasal hairs suggest airway burns, a life-threatening condition requiring immediate airway assessment and management.