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A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample
- B. Check the clients' 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 is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.
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A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
- A. Neurovascular assessment
- B. Braden scale
- C. Pain assessment
- D. Morse Fall Risk scale
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
- A. Initiate airborne precautions
- B. Ensure the clients bed is positioned to greater than 45°
- C. Encourage frequent ambulation
- D. Ensure lights are dimmed in the clients room
Correct Answer: D
Rationale: The correct answer is D: Ensure lights are dimmed in the client's room. Dimming the lights can help decrease stimulation and minimize discomfort for a client with bacterial meningitis, as they may be sensitive to light due to photophobia, which is a common symptom in meningitis. It can also help reduce the risk of exacerbating headaches and other symptoms.
Incorrect choices:
A: Initiating airborne precautions is not necessary for bacterial meningitis, as it is not transmitted through the air.
B: Ensuring the client's bed is positioned to greater than 45° is not directly related to the care of a client with bacterial meningitis.
C: Encouraging frequent ambulation may not be appropriate for a client with bacterial meningitis, as they may be too weak or ill to ambulate.
E, F, G: There are no additional choices provided, but they would likely be incorrect as they are not relevant to the care of a client with bacterial meningitis.
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, leading to occult blood in the stool. Monitoring stool for occult blood helps in detecting any gastrointestinal bleeding early. Serum calcium (A) is not typically affected by long-term ibuprofen use. Fasting blood glucose (C) is not directly related to ibuprofen use. Urine for white blood cells (D) is not relevant in this scenario.
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries
- B. I often have diarrhea after eating scrambled eggs
- C. I have trouble urinating if I eat acidic foods
- D. I sometimes start to wheeze when I eat peanuts
Correct Answer: A
Rationale: The correct answer is A because a client who experiences a rash when eating strawberries may have a latex allergy due to cross-reactivity between latex and certain fruits like strawberries. This is known as latex-fruit syndrome. The other choices (B, C, D) do not indicate a potential latex allergy and are unrelated symptoms. It's important for the nurse to recognize this risk factor to prevent an allergic reaction during surgery.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Painless vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Painless vaginal bleeding. Cervical cancer can present with abnormal vaginal bleeding, which may include bleeding between periods, after intercourse, or post-menopause. This is due to the abnormal growth of cells in the cervix. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typical manifestations of cervical cancer. Diarrhea and urinary hesitancy are more commonly associated with gastrointestinal or urinary tract issues, while unexplained weight gain can be linked to various factors such as hormonal imbalances or dietary changes.