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A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Headache
- B. Dyspnea
- C. Hyperthermia
- D. Urticaria
Correct Answer: B
Rationale: Dyspnea may indicate a severe transfusion reaction like TRALI, requiring urgent reporting.
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A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client is wearing nail polish.
- B. The client has an elevated hemoglobin level.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: A
Rationale: Nail polish can block light in pulse oximetry, leading to inaccurate low readings.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. You need to talk with your doctor about this.
- C. Why are you refusing to receive blood products?
- D. I understand that you decided not to receive blood products.
Correct Answer: D
Rationale: Acknowledging the refusal respects autonomy and builds trust, avoiding confrontation.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Infection control. C: Proper site. E: Disinfection; A causes hemolysis, D reduces blood flow.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Use a fan to circulate air in the client's room.
- C. Place the head of the client's bed flat.
- D. Provide oral care to the client once every 8 hr.
Correct Answer: B
Rationale: A fan reduces breathlessness sensation, improving comfort in dyspnea.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start performing monthly breast self-examinations at age 35.
- B. You should receive a breast examination from your provider each year after age 30.
- C. You should receive a breast ultrasound every 3 years after age 50.
- D. You should start receiving mammograms as early as age 40.
Correct Answer: D
Rationale: Mammograms starting at 40 align with standard screening guidelines for average-risk women.