Nokea
A man‘s blood type is AB and he requires a blood transfusion. To prevent complications of blood incompatibilities, which blood type may the client receive?
- A. Type A or B blood only
- B. Type O blood only
- C. Type AB blood only
- D. Either type A, B, AB, or O blood
Correct Answer: D
Rationale: The correct answer is D because individuals with AB blood type are considered universal recipients, meaning they can receive blood from any blood type without risking complications due to incompatibility. This is because their blood cells have both A and B antigens and do not produce antibodies against either type. Therefore, the client can safely receive blood from types A, B, AB, or O without adverse reactions.
Choices A, B, and C are incorrect because they limit the options for blood transfusion based on the client's AB blood type, which is not necessary given the unique nature of AB blood as universal recipients.
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A narcotic analgesic is ordered for postoperative pain. Why are narcotics given in low doses to the laryngectomy patient?
- A. They depress the respiratory rate and cough reflex.
- B. They increase respiratory tract secretions.
- C. They have a tendency to cause stomal edema.
- D. They can cause addiction.
Correct Answer: A
Rationale: The correct answer is A because narcotics in high doses can depress the respiratory rate and cough reflex, which can be especially dangerous for a laryngectomy patient due to the risk of airway compromise. Low doses can provide pain relief without significant respiratory depression. Choices B and C are incorrect because narcotics typically do not increase respiratory tract secretions or cause stomal edema. Choice D is incorrect because while narcotics can potentially cause addiction, this is not the primary reason for giving low doses to laryngectomy patients.
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
- A. Reassess the patient.
- B. Notify the health care provider.
- C. Administer a prn medication for pain.
- D. Call radiology for a portable chest x-ray.
Correct Answer: B
Rationale: The correct answer is B, notifying the health care provider. This is the most appropriate initial intervention because chest pain can be a symptom of a serious medical condition like a heart attack. The health care provider needs to be informed immediately to assess the situation and provide appropriate treatment. Reassessing the patient (A) may delay crucial medical intervention. Administering pain medication (C) without knowing the cause of chest pain can be dangerous. Calling radiology for a chest x-ray (D) is not the initial step in managing new onset chest pain.
20-year old Mr. Ang fell off from his horse, and sustained a lft hip fracture. Buck’s extension traction is applied. The following statements are true about Buck’s extension traction except:
- A. used as a temporary measure in adults to control muscle spasm and pain
- B. applied by orthopedic surgeon under aseptic conditions using wires and pins
- C. The pulling force is transmitted to the musculoskeletal structures
- D. used definitively to treat fractures in children
Correct Answer: D
Rationale: The correct answer is D because Buck's extension traction is not used definitively to treat fractures in children due to their growing bones. Instead, it is used temporarily in adults to control muscle spasm and pain.
- A: Correct - Buck's extension traction is indeed used temporarily in adults to control muscle spasm and pain.
- B: Correct - Buck's extension traction is applied by an orthopedic surgeon under aseptic conditions using wires and pins.
- C: Correct - The pulling force in Buck's extension traction is indeed transmitted to the musculoskeletal structures.
Therefore, the incorrect option is D as Buck's extension traction is not used definitively to treat fractures in children.
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
- A. Is written as a two-part statement
- B. Describes human response to a health problem
- C. Describes potential for enhancement to a higher state
- D. Made when not enough evidence supports the problem
Correct Answer: A
Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue.
Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.
An adult is receiving NSAID. Which of the following would the nurse include in the teaching about this medication?
- A. Take NSAID with aspiring for full effect
- B. Take the NSAID with meals
- C. Orange juice will help to potentiate the effect of NSAID
- D. The NSAID will coat the stomach lining
Correct Answer: B
Rationale: The correct answer is B: Take the NSAID with meals. Taking NSAIDs with meals helps reduce stomach irritation and risk of developing ulcers. Food acts as a protective barrier and helps in the absorption of the medication.
Incorrect Choices:
A: Taking NSAID with aspirin can increase the risk of stomach irritation and bleeding due to combined antiplatelet effects.
C: Orange juice does not potentiate the effect of NSAIDs and may even worsen stomach irritation due to its acidity.
D: NSAIDs do not coat the stomach lining; in fact, they can irritate the stomach lining and increase the risk of ulcers.