Nokea
A client's blood pressure is 132/84. What is the mean arterial pressure?
- A. 79 mmHg
- B. 48 mmHg
- C. 92 mmHg
- D. 100 mmHg
Correct Answer: C
Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.
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Which symptom is not associated with glaucoma?
- A. Veil-like loss of vision
- B. Foggy loss of vision
- C. Seeing halos around lights
- D. Complaints of eye pain
Correct Answer: A
Rationale: Veil-like loss of vision is not typical of glaucoma; foggy vision, halos, and eye pain are common symptoms.
Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?
- A. Slow the transfusion rate and administer diphenhydramine.
- B. Stop the transfusion and notify the physician.
- C. Increase the transfusion rate to complete it quickly.
- D. Administer acetaminophen for discomfort.
Correct Answer: B
Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority
A client has surgery scheduled in 2 weeks. He decides to donate his own blood ahead of time to be stored and used in case he needs a blood transfusion during his surgery. This type of blood donation is referred to as
- A. an allogeneic donation.
- B. an xenogeneic donation.
- C. an autologous donation.
- D. a directed donation.
Correct Answer: C
Rationale: Autologous donation involves donating one’s own blood for personal use during surgery, reducing transfusion risks.
Which statement by the client regarding sickle cell disease indicates a need for further teaching?
- A. I should avoid strenuous exercise.
- B. I can enjoy one glass of red wine per day.
- C. I will avoid cigarettes and all tobacco products.
- D. I should avoid traveling to places at high altitudes such as Denver.
Correct Answer: B
Rationale: Alcohol, including red wine, can cause dehydration and increase the risk of sickle cell crisis, so it should be avoided. Other statements are correct.