Nokea
A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?
- A. Low back pain
- B. Tachycardia
- C. Flushed skin
- D. Headache
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. Tachycardia can indicate a hemolytic transfusion reaction, a severe and life-threatening complication of blood transfusion. The nurse should report tachycardia immediately to prevent further complications. Low back pain, flushed skin, and headache are also important to monitor during a blood transfusion, but they are not as indicative of a severe transfusion reaction as tachycardia.
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How should a healthcare professional assess for infection in a patient post-surgery?
- A. Check the surgical site
- B. Check for fever
- C. Check for abnormal breath sounds
- D. Check the patient's skin color
Correct Answer: A
Rationale: When assessing for infection in a patient post-surgery, checking the surgical site is crucial. Changes in the appearance of the surgical site, such as redness, swelling, warmth, or drainage, can indicate an infection. While checking for fever (Choice B) is also important as it can be a sign of infection, it is a more general symptom and may not always be present. Checking for abnormal breath sounds (Choice C) and skin color (Choice D) are not typically direct indicators of infection in a post-surgery patient.
What is the best dietary recommendation for a patient with chronic kidney disease?
- A. Low-protein diet
- B. High-protein diet
- C. Low-sodium diet
- D. High-sodium diet
Correct Answer: C
Rationale: The correct answer is a low-sodium diet. Patients with chronic kidney disease are often advised to follow a low-sodium diet to help manage fluid retention. Excessive sodium intake can lead to fluid buildup in the body, causing complications for individuals with kidney issues. Choices A and B are incorrect because while protein intake may need to be monitored in kidney disease, the primary focus is typically on sodium restriction. Choice D is incorrect as a high-sodium diet would exacerbate fluid retention in patients with chronic kidney disease.
A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?
- A. Fasting blood glucose
- B. Carbohydrate intake
- C. Hematocrit
- D. Weight
Correct Answer: D
Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.
A client is receiving heparin therapy. Which of the following laboratory results indicates the client is receiving an effective dose of heparin?
- A. INR 1.5
- B. aPTT 60 seconds
- C. Platelets 150,000/mm³
- D. Potassium 4.0 mEq/L
Correct Answer: B
Rationale: An aPTT of 60 seconds indicates the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for a clot to form, and a therapeutic range for heparin therapy is usually 1.5 to 2 times the control value, which is around 60-80 seconds. An INR of 1.5 is not related to heparin therapy, as it is commonly used to monitor warfarin therapy. Platelet count and potassium levels are not direct indicators of the effectiveness of heparin therapy.
What is the first action for a healthcare provider when a patient experiences a fall?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct answer is to 'Assess the patient for injuries' when a patient experiences a fall. This is crucial to promptly identify any injuries and provide appropriate care. Calling for help may be necessary, but assessing the patient's condition takes precedence to ensure immediate attention to any injuries. Documenting the fall and notifying the healthcare provider would follow after the initial assessment and necessary actions have been taken.