Nokea
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
- A. Call for both clients' blood transfusions at the same time.
- B. Ask the nurse to verify the compatibility of both units at the same time.
- C. Call for and hang the first client's blood transfusion.
- D. Ask another nurse to call for and hang the blood for the second client.
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.
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A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, 'Why does she have this tube inserted in her hip?' Which of the following responses would be best?
- A. The tube helps us to detect a wound infection early on.'
- B. This way we won't have to irrigate the wound.'
- C. Fluid won't be allowed to accumulate at the site.'
- D. We have a way to administer antibiotics into the wound.'
Correct Answer: C
Rationale: The drainage tube prevents fluid accumulation, reducing infection risk and promoting healing.
Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?
- A. A change in the pattern of her pain.
- B. Pain during sexual activity.
- C. Pain during an argument with her husband.
- D. Pain during or after an activity such as lawn-mowing.
Correct Answer: A
Rationale: A change in the pattern of angina pain may indicate worsening ischemia or progression to unstable angina or MI, requiring immediate medical attention.
The nurse is caring for a client with a hyphema. The nurse should plan to take which action?
- A. Shield the affected eye.
- B. Place the client supine.
- C. Apply a cold compress to the eye.
- D. Request a prescription for aspirin.
Correct Answer: A
Rationale: Shielding the affected eye protects it from further injury in hyphema (blood in the anterior chamber). Supine positioning may worsen bleeding, cold compresses are not standard, and aspirin increases bleeding risk.
As a result of a gastric resection, the client is at risk for development of dumping syndrome. The nurse should prepare a plan of care for this client based on knowledge that this problem stems primarily from which of the following gastrointestinal changes?
- A. Excess secretion of digestive enzymes in the intestines.
- B. Rapid emptying of stomach contents into the small intestine.
- C. Excess glycogen production by the liver.
- D. Loss of gastric enzymes.
Correct Answer: B
Rationale: Dumping syndrome occurs due to rapid emptying of stomach contents into the small intestine, causing osmotic and vasomotor symptoms. The other options are not primary causes.
The nurse is caring for a client with Crohn's disease who reports frequent nighttime diarrhea. Which intervention should the nurse prioritize?
- A. Administer an antidiarrheal as ordered.
- B. Encourage a high-fiber diet.
- C. Schedule meals earlier in the day.
- D. Provide a bedside commode.
Correct Answer: D
Rationale: Providing a bedside commode is the priority to ensure safety and comfort for a client with frequent nighttime diarrhea due to Crohn's disease. Antidiarrheals may be used but require careful monitoring, a high-fiber diet may worsen symptoms, and meal timing is less impactful. CN: Physiological adaptation; CL: Synthesize