Nokea
A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
- A. Elevate the limb and apply ice.
- B. Apply a tourniquet just below the elbow.
- C. Apply direct pressure over the wound.
- D. Clean the wound.
Correct Answer: C
Rationale: Applying direct pressure is the first-line intervention to control profuse bleeding, stopping or reducing blood loss immediately.
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A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
- A. Hemoglobin level
- B. Fluid intake
- C. Temperature
- D. Skin color
Correct Answer: C
Rationale: A baseline temperature is crucial to monitor for febrile reactions during transfusion. A significant rise indicates a reaction requiring intervention. Other data are less immediate.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
- A. Packed RBCS
- B. Fresh frozen plasma
- C. Recombinant
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Recombinant factor VIII is a synthetic form of the clotting factor deficient in hemophilia A, used to increase factor VIII levels before procedures to prevent excessive bleeding. Packed RBCs treat anemia, not clotting deficiencies. Fresh frozen plasma contains all clotting factors but is less targeted than recombinant factor VIII. Prophylactic antibiotics prevent infection, not bleeding.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. 2 hr after obtaining blood from the blood bank
- B. When the client states he is ready to start the infusion
- C. As soon as the nurse can prepare the client and the administration set
- D. when the client has finished eating lunch
Correct Answer: C
Rationale: Blood products should be infused as soon as possible after preparation, ideally within 30 minutes, to reduce bacterial contamination risk and ensure efficacy.
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?
- A. Avoid crowds
- B. Eat plenty of fresh fruits and vegetables
- C. Take temperature weekly.
- D. Perform mild exercise, such as gardening
Correct Answer: A
Rationale: Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens. Fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early. Gardening can expose individuals to soil-borne organisms that could lead to infections.
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
- A. Massage over erythematous bony prominences.
- B. Implement a turning schedule every 4 hr.
- C. Keep the client's skin dry with powder.
- D. Minimize skin exposure to moisture.
- E. Use pillows to keep heels off the bed surface
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.