Nokea
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
- A. The first 2 min
- B. The final 2 min
- C. The final 15 min
- D. The first 15 min
Correct Answer: D
Rationale: Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for signs of a reaction, such as fever, chills, rash, or difficulty breathing.
You may also like to solve these questions
A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience retinal detachment. Which of the following statements should the nurse include in the teaching?
- A. Vision changes occur suddenly due to complete obstruction of aqueous humor outflow
- B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye
- C. Vision changes occur when the retina begins to breakdown and collect bits of debris
- D. Vision changes occur when the cloudy lens alters the passage of light through the eye
Correct Answer: B
Rationale: Retinal detachment occurs when the retina separates from its supporting tissues and blood vessels, leading to vision loss. Other options describe different eye conditions like glaucoma, macular degeneration, or cataracts.
A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?
- A. Mood changes
- B. Mobility challenges
- C. Shortness of breath
- D. Sleep disturbance
Correct Answer: A,B,C,D
Rationale: B12 deficiency can cause mood changes (neurological effects), mobility challenges (neuropathy), shortness of breath (anemia), and visual deficits (optic nerve damage). Sleep disturbance is not typical.
A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify which of the following persons is qualified?
- A. Phlebotomist
- B. Assistive personnel
- C. Senior nursing student
- D. Oncology nurse
Correct Answer: D
Rationale: An oncology nurse is a registered nurse with specialized training and experience in administering blood products, making them qualified to double-check blood labels and patient identification. Phlebotomists, assistive personnel, and senior nursing students lack the required training or authority for this critical safety task.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
- A. Wash with plain soap and water.
- B. sit in the sun for 10 min per day.
- C. Apply moist heat.
- D. Apply hydrating lotions.
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.