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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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.
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?
- A. A sunken fontanel
- B. Decreased pulse rate
- C. Increased blood pressure
- D. Low urine specific gravity
Correct Answer: A
Rationale: A sunken fontanel is a classic sign of dehydration in infants. When a child is experiencing fluid volume deficit, the body's priority is to maintain blood flow to vital organs, resulting in decreased blood circulation to the skin and extremities. Consequently, decreased skin turgor and a sunken fontanel are common manifestations of dehydration. Other signs of fluid volume deficit may include dry mucous membranes, lethargy, decreased urine output, and increased heart rate.
An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
- A. Assess for neurologic defects
- B. Place the child in the knee-chest position
- C. Begin cardiopulmonary resuscitation
- D. Prepare family for imminent death
Correct Answer: B
Rationale: When an 8-month-old infant has a hypercyanotic spell, the priority nursing action is to place the child in the knee-chest position. This position helps to increase venous return to the heart and improve systemic circulation, which can relieve the cyanosis by decreasing right-to-left shunting of blood. Placing the child in the knee-chest position helps optimize oxygenation and circulation, which is crucial during a hypercyanotic spell. Assessing for neurologic defects, beginning cardiopulmonary resuscitation, or preparing the family for imminent death are not the priority actions during a hypercyanotic spell in this scenario.
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
- A. Imbalanced nutrition:Less than body requirements related to poor intake
- B. Disturbed sleep pattern related to external stimuli
- C. Impaired skin integrity related to pruritus
- D. Pain related to sickle cell crisis
Correct Answer: D
Rationale: Sickle cell crisis is characterized by intense pain due to the vaso-occlusive properties of sickled red blood cells leading to tissue ischemia. Therefore, pain is the primary nursing diagnosis that the nurse should expect to see in the plan of care for a client experiencing a sickle cell crisis. Managing and alleviating the pain is a priority in the care of these clients to improve quality of life and prevent complications. Other nursing diagnoses such as imbalanced nutrition, disturbed sleep pattern, and impaired skin integrity may not be directly related to the acute crisis and would not be the priority focus of care in this situation.
Which of the ff conditions is evident by persistent hoarseness?
- A. Bacterial infection
- B. Aphonia
- C. Laryngeal cancer
- D. Peritonsillar abscess
Correct Answer: C
Rationale: Persistent hoarseness is often a symptom of laryngeal cancer. Laryngeal cancer affects the voice box, leading to changes in voice quality, such as hoarseness. It is important to seek medical evaluation if hoarseness lasts for more than two weeks, as early detection and treatment of laryngeal cancer can improve outcomes. Bacterial infection, aphonia (loss of voice), and peritonsillar abscess are not typically associated with persistent hoarseness as a primary symptom.