Nokea
A nurse is caring for a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the client's condition?(Select All that Apply.)
- A. D-dimer blood test
- B. Complete blood count (CBC)
- C. CT scan
- D. Chest x-ray
- E. Lung ventilation and perfusion scan (VQ scan)
Correct Answer: A,C,E
Rationale: A D-dimer test measures clot breakdown products in the blood, with elevated levels suggesting the presence of an abnormal blood clot like in PE. A CT pulmonary angiography is the gold standard for diagnosing PE, providing detailed images of the lung's blood vessels. A VQ scan is another diagnostic tool for PE, especially for clients who cannot tolerate contrast dye, as it identifies ventilation-perfusion mismatches suggestive of PE. A CBC is not typically used to diagnose PE, and a chest x-ray is performed to rule out other causes but does not confirm PE.
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A nurse is caring for a client with a chronic wound. Which of the following is a potential complication of a chronic wound?
- A. Electrolyte abnormalities
- B. Altered hemoglobin ATC
- C. Psychological distress
- D. Fluid volume overload
Correct Answer: C
Rationale: Chronic wounds can lead to significant emotional and psychological stress due to prolonged treatment, appearance issues, and limitations in activities. Electrolyte abnormalities are not typically a direct complication unless associated with severe infections or extensive fluid loss, which is uncommon. The wound itself does not directly alter hemoglobin A1C, which measures long-term blood glucose control. Fluid volume overload is not a direct complication of chronic wounds.
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.
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Administer diphenhydramine, Administer an antibiotic, Administer furosemide, Stop transfusion
- B. Transfusion reaction, Transfusion associated circulatory overload, Acute extravasation
- C. Hives, Weight, Low back pain, Respiratory rate
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
- A. Keep family members aware of his condition.
- B. Talk with the client during wound care.
- C. Rotate nursing staff so he can have varied interactions.
- D. Assign assistive personnel to keep his room neat and clean.
Correct Answer: B
Rationale: Talking with the client during wound care builds trust, provides emotional support, and helps cope with pain and stress. Other options are less directly supportive emotionally.