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A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
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Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- B. Report the COVID-19 result to the local health department according to CDC guidelines.
- C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: A
Rationale: Isolating the client immediately prevents potential COVID-19 transmission, given the suggestive symptoms, and is the priority action before reporting, educating, or contact tracing.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Avoiding high-fat foods like whole milk and ice cream prevents exacerbation of cholecystitis, demonstrating effective understanding of dietary restrictions.
A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Administer analgesics on a fixed and continuous schedule.
- B. Frequently evaluate the client's pain.
- C. Replace transdermal analgesic patches every 72 hours.
- D. Monitor client for break-through pain.
Correct Answer: A
Rationale: A fixed and continuous analgesic schedule ensures consistent pain relief for chronic severe cancer pain, preventing fluctuations and addressing inadequate response to the initial dose.
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?
- A. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- B. Give a prescribed analgesic for temperature above 101°F (38.3° C).
- C. Place an indwelling urinary catheter and attach a bedside drainage unit.
- D. Send the client to x-ray for a flat plate of the abdomen.
Correct Answer: A
Rationale: Inserting an NGT with low intermittent suction decompresses the stomach, removes gastric contents, and relieves vomiting and pain, addressing the acute symptoms of peptic ulcer exacerbation first.
An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?
- A. Teach the client relaxation techniques.
- B. Determine the client's food preferences.
- C. Maintain a patent intravenous site.
- D. Keep room temperature cool.
Correct Answer: C
Rationale: Maintaining a patent IV site allows administration of fluids, electrolytes, and nutrients, addressing the critical dehydration and malnutrition in Grave's disease, which takes precedence over other supportive measures.