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A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 minutes after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample.
- B. Check the client's vital signs.
- C. Stop the infusion.
- D. Administer oxygen to the client.
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client's symptoms suggest a transfusion reaction, which could be life-threatening. Stopping the infusion is the priority to prevent further harm. Checking vital signs can wait, as immediate action is needed. Collecting a urine sample is not urgent in this situation. Administering oxygen is not indicated unless the client shows signs of respiratory distress, which is not mentioned in the scenario.
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A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my digoxin if my pulse is less than 50 beats per minute.
- B. I will take this medication with fiber to prevent constipation.
- C. I will increase my dose if my vision becomes blurred.
- D. I will notify my provider if I experience muscle weakness.
Correct Answer: D
Rationale: Rationale for Correct Answer (D):
The correct answer is D because muscle weakness is a potential sign of digoxin toxicity. It is crucial for the client to notify the provider immediately to prevent serious complications. This statement indicates an understanding of the teaching regarding digoxin therapy.
Summary of Incorrect Choices:
A: Incorrect. Taking digoxin with a pulse less than 50 beats per minute can lead to bradycardia and toxicity.
B: Incorrect. Taking digoxin with fiber may decrease its absorption, reducing its effectiveness.
C: Incorrect. Blurred vision is a sign of digoxin toxicity, and the dose should be decreased, not increased.
A nurse is caring for a client who has heart failure. Which of the following findings indicate the client is at risk for developing complications?
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A, dysrhythmias. In heart failure, the heart's inability to pump effectively can lead to electrical disturbances causing dysrhythmias, which can be life-threatening. Dysrhythmias can result in decreased cardiac output, further exacerbating heart failure. Respiratory alkalosis (B) is not a direct complication of heart failure. Acute kidney injury (C) can occur due to decreased cardiac output, leading to decreased renal perfusion, but it is not a direct risk factor for complications in heart failure. Fluid volume deficit (D) is a common finding in heart failure due to fluid retention, but it is not a direct risk for complications like dysrhythmias.
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions isn't appropriate?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: C
Rationale: Correct Answer: C - Infuse 0.9% sodium chloride if the solution is not available.
Rationale: TPN is a specialized form of nutrition that must be administered precisely as prescribed to prevent complications. Infusing 0.9% sodium chloride instead of the prescribed TPN solution can lead to imbalanced nutrient intake and electrolyte disturbances. It is crucial to follow the prescribed TPN regimen accurately to meet the client's specific nutritional needs.
Incorrect Choices:
A: Monitoring serum blood glucose during infusion is appropriate to ensure the client's glycemic control while on TPN.
B: Obtaining the client's weight daily is important to assess fluid status and adjust the TPN prescription as needed.
D: Verifying the TPN solution with another RN prior to infusion is a standard safety practice to prevent errors in administration.