Nokea
A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
- A. A hemolytic reaction to mismatched blood
- B. A hemolytic reaction to Rh-incompatible blood
- C. A hemolytic allergic reaction caused by bacterial contamination of donor blood
- D. None of the above
Correct Answer: A
Rationale: The client is likely experiencing a hemolytic reaction to mismatched blood due to the symptoms of chills, dyspnea, and urticaria occurring shortly after beginning the blood transfusion. These symptoms are classic signs of a transfusion reaction, especially a hemolytic reaction where the recipient's immune system attacks the transfused red blood cells. This can happen if the donor blood is not compatible with the recipient's blood type, leading to a severe reaction. It is crucial to report this immediately to the physician to halt the transfusion and provide appropriate treatment to the client.
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A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Early onset of puberty
- C. Sexually transmitted disease
- D. Cryptorchidism
Correct Answer: D
Rationale: Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer. Men who had cryptorchidism, a condition where one or both testicles fail to descend into the scrotum before birth, have a higher risk of developing testicular cancer compared to those without this condition. The abnormal positioning of the testicle outside the scrotum may disrupt normal testicular development and increase the likelihood of malignant transformation. Therefore, clients with a history of cryptorchidism are at increased risk for testicular cancer and warrant close monitoring and follow-up.
7-year-old Damon has cystitis; which of the following would Nurse Elena expect when assessing the child?
- A. Dysuria
- B. Costovertebral tenderness
- C. Flank pain
- D. High fever
Correct Answer: A
Rationale: Cystitis is inflammation of the bladder, commonly caused by a bacterial infection. In children, symptoms of cystitis often include dysuria, which is painful or difficult urination. This symptom is frequently observed in children with cystitis. Costovertebral tenderness and flank pain are more indicative of kidney involvement (such as in pyelonephritis) rather than just bladder inflammation like in cystitis. High fever may also be present in severe cases of cystitis, but dysuria is the more specific and common symptom associated with this condition in children.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
- A. Hypoalbuminemia with hemoconcentration
- B. Volume overload with hemodilution
- C. Metabolic acidosis
- D. Lack of erythropoeitin factor
Correct Answer: B
Rationale: A reduced hematocrit (Hct) in a client with deep partial-thickness burns can be primarily caused by volume overload with hemodilution. In patients with burns, there is an initial shift of fluid from the intravascular space to the interstitial space, leading to a decreased intravascular volume. In response to this hypovolemia, there is an increased release of antidiuretic hormone (ADH) and aldosterone, resulting in retention of water and sodium. This volume overload leads to hemodilution, where the proportion of red blood cells to plasma decreases, causing a reduction in hematocrit levels. This scenario is a common occurrence in clients with burn injuries and helps explain the reduced hematocrit in this client.
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: When a woman expresses concerns about a possible Chlamydia infection, the nurse should prepare a Chlamydia collection kit for the primary care provider. This kit typically includes everything needed to collect a specimen for testing, such as a swab for the patient to provide a genital sample. This sample can then be sent to a laboratory for testing to confirm the presence of Chlamydia. Having the appropriate collection kit ready ensures that the primary care provider can promptly gather the necessary information to make an accurate diagnosis and provide appropriate treatment if needed.
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
- A. Pedal edema
- B. Pink, frothy sputum
- C. Jugular vein distention
- D. Bradycardia
Correct Answer: B
Rationale: Furosemide IV is a diuretic medication commonly used to treat conditions such as pulmonary edema. In the case of pulmonary edema, the excess fluid accumulates in the lungs, leading to symptoms such as difficulty breathing, wheezing, and the production of pink, frothy sputum. The presence of pink, frothy sputum is a classic sign of pulmonary edema and indicates the presence of fluid in the airways. Therefore, the nurse would evaluate the effectiveness of furosemide IV treatment by monitoring the resolution of this specific symptom, as it indicates improvement in the underlying condition of pulmonary edema.