Nokea
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
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A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
- A. Check the results of the client's most recent CBC
- B. Administer a blood transfusion
- C. Offer the client a stimulant medication
- D. Advise the client to reduce physical activity
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (B) should not be done without confirming the need through lab results. Offering a stimulant medication (C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (D) may not address the root cause of the fatigue.
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Tinel's sign
- B. Phalen's test
- C. Rinne's test
- D. Romberg test
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. Phalen's test is used to assess for carpal tunnel syndrome by having the client flex the wrists and press the backs of the hands together for 1 minute to compress the median nerve. This test reproduces symptoms in individuals with carpal tunnel syndrome due to increased pressure on the median nerve. Tinel's sign (A) is used to assess for nerve compression, but it is not specific to carpal tunnel syndrome. Rinne's test (C) is used to assess for hearing loss. Romberg test (D) is used to assess for balance and proprioception issues. Choices E, F, and G are not relevant to assessing carpal tunnel syndrome.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?
- A. Hair loss
- B. Nausea and vomiting
- C. Fatigue
- D. Skin irritation
Correct Answer: C
Rationale: The correct answer is C: Fatigue. Radiation treatment can cause fatigue as it affects healthy cells in addition to cancer cells, leading to increased tiredness. Hair loss (A) is more commonly associated with chemotherapy, while nausea and vomiting (B) are typical side effects of chemotherapy or certain medications. Skin irritation (D) is a common side effect of radiation treatment, but fatigue is the primary adverse effect in this scenario due to its impact on overall energy levels.
A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
- A. Eye pain
- B. Sudden vision loss
- C. Decreased ability to perceive colors
- D. Excessive tearing
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (A) is not a typical symptom of cataracts. Sudden vision loss (B) is more commonly associated with conditions like retinal detachment. Excessive tearing (D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.