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A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if a transfusion reaction is suspected?
- A. Increase the infusion rate.
- B. Administer diphenhydramine.
- C. Stop the transfusion.
- D. Elevate the client's legs.
Correct Answer: C
Rationale: Stopping the transfusion prevents further reaction. Increasing the rate worsens it, diphenhydramine is secondary, and leg elevation is unrelated.
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A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?
- A. Patient Health questionnaire 9
- B. Mental Status Examination
- C. Brief Psychiatric Rating Scale
- D. Abnormal Involuntary Movement Scale
Correct Answer: D
Rationale: The AIMS is designed to detect tardive dyskinesia, a side effect of antipsychotics. Other tools assess depression, cognition, or general psychiatric symptoms.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
A nurse is reinforcing teaching with a client who has a new prescription for pantoprazole. Which of the following statements should the nurse include?
- A. Take this medication at bedtime.
- B. You might have diarrhea while taking this medication.
- C. You need to take this medication with an antacid.
- D. You should stop taking this medication if your symptoms improve.
Correct Answer: B
Rationale: Pantoprazole can cause diarrhea, a side effect to monitor. It's taken before meals, antacids aren't needed, and stopping early risks relapse.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Remind the client of the day and time often.
- B. Offer the client several choices at mealtimes.
- C. Avoid discussing the client's fears.
- D. Alternate daily caregivers.
Correct Answer: A
Rationale: Frequent orientation to time and place reduces confusion in delirium. Multiple choices can overwhelm, discussing fears supports emotional needs, and consistent caregivers minimize disorientation.
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Encourage the client to flex the knee every 2 hr.
- B. Apply a continuous passive motion machine as prescribed.
- C. Instruct the client to keep the leg in a dependent position.
- D. Administer a diuretic to reduce swelling.
Correct Answer: B
Rationale: A CPM machine promotes mobility and prevents stiffness as prescribed. Flexion timing varies, dependent positioning increases swelling, and diuretics aren't routine.