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A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.
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A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. The first action the nurse should take is to...
- A. notify the provider of increased pain followed by elevating the extremity at level of the heart.
- B. check the client's oxygen saturation followed by administering pain medication.
- C. assess the client's incision site followed by applying a cold pack.
- D. monitor the client's vital signs followed by documenting the findings.
Correct Answer: A
Rationale: Post-ORIF, increased pain (Day 2, 1600) suggests compartment syndrome, a surgical emergency requiring immediate provider notification to evaluate for fasciotomy. Elevating the extremity at heart level balances perfusion without worsening pressure, unlike high elevation which reduces blood flow. Checking oxygen saturation and medicating pain address symptoms, not the cause pain here signals ischemia, not hypoxia. Assessing the incision (e.g., swelling) supports suspicion, but notification trumps delay; cold packs may mask signs. Monitoring vital signs is routine, but pain's acuity demands action over documentation. Prompt reporting aligns with the 6 Ps, prioritizing limb salvage, making it the critical first step.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Prescription: Administer an iron supplement.
- A. Administer an iron supplement
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid Intake.
Correct Answer:
Rationale: Low Hct, Hgb, and ferritin indicate iron deficiency anemia, making iron supplementation anticipated.
A nurse is reinforcing teaching with an older adult client who is postoperative following a transurethral resection of the prostate. Which of the following statements should the nurse include in the teaching?
- A. You should take ibuprofen for discomfort.
- B. You should wait 6 weeks before resuming sexual intercourse.
- C. You may tub bathe until the catheter is removed.
- D. You may drive after 1 week.
Correct Answer: B
Rationale: Post-transurethral resection of the prostate (TURP), teaching focuses on healing and preventing complications like bleeding or infection. Waiting 6 weeks before resuming sexual intercourse allows the prostatic fossa to heal, reducing risks of hemorrhage or irritation, a standard guideline post-TURP. Ibuprofen, an NSAID, increases bleeding risk by inhibiting platelet function, contraindicated with fresh surgical sites. Tub bathing with a catheter risks introducing bacteria into the urinary tract, so showers are preferred until removal. Driving after 1 week may be premature recovery varies, and catheter presence or pain could impair safety; typically, 2-4 weeks is advised. The 6-week sexual abstinence instruction aligns with urologic care protocols, promotes safe recovery, and addresses a common patient concern, making it the most appropriate teaching point to ensure long-term outcomes and minimize rehospitalization.
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Hydrogen peroxide
- C. Bleach
- D. Chlorhexidine
Correct Answer: C
Rationale: AIDS, caused by HIV, requires strict infection control due to bloodborne transmission risk. Option C, bleach (typically a 1:10 dilution with water), is correct CDC guidelines recommend it for disinfecting HIV-contaminated surfaces, as it effectively inactivates the virus by denaturing proteins. Option A, isopropyl alcohol, disinfects but isn't the standard for blood spills; it evaporates quickly, potentially leaving viable pathogens. Option B, hydrogen peroxide, oxidizes but lacks evidence as a primary bloodborne pathogen disinfectant compared to bleach. Option D, chlorhexidine, excels for skin antisepsis, not environmental surfaces or blood cleanup. Bleach's broad-spectrum efficacy, affordability, and alignment with universal precautions make it the gold standard. Teaching this ensures the new nurse protects themselves and others, adhering to OSHA and hospital protocols, while reinforcing the importance of proper dilution (e.g., 1 part bleach to 9 parts water) for safety and effectiveness.
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
- A. Confusion
- B. Hypothermia
- C. Referred pain in the right shoulder
- D. Orange colored urine
- E. Fever
- F. Dysuria
- G. Urgency
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.