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A nurse is caring for a patient who is receiving a blood transfusion. The patient reports chills and back pain 15 minutes after the transfusion begins. Which of the following actions should the nurse take first? What should the nurse do first for transfusion reaction symptoms?
- A. Slow the transfusion rate.
- B. Stop the transfusion.
- C. Administer acetaminophen.
- D. Notify the provider.
Correct Answer: B
Rationale: The correct answer is B: Stop the transfusion. When a patient develops symptoms of a transfusion reaction such as chills and back pain, it is crucial to stop the transfusion immediately to prevent further complications. This action takes priority over other options as it ensures patient safety. Slowing the transfusion rate (choice A) may not be sufficient to address the reaction promptly. Administering acetaminophen (choice C) may help alleviate symptoms but does not address the underlying cause. Notifying the provider (choice D) is important but should come after stopping the transfusion to address the immediate issue.
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A nurse is caring for a patient who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider? Which finding post-cholecystectomy should the nurse report?
- A. Clay-colored stools
- B. Mild abdominal pain
- C. Nausea
- D. Fatigue
Correct Answer: A
Rationale: Correct Answer: A: Clay-colored stools
Rationale: Clay-colored stools can indicate a potential issue with bile flow, which is crucial post-cholecystectomy. Absence of bile in the stool may suggest a blocked bile duct, leading to complications like jaundice or infection. This finding should be reported promptly for further evaluation and management.
Summary of other choices:
- B: Mild abdominal pain is common post-surgery and can be managed with pain medications.
- C: Nausea is also expected after surgery and can be managed with antiemetics.
- D: Fatigue is a common postoperative symptom and may improve with rest and proper nutrition.
A nurse is caring for a patient who has a new prescription for gabapentin. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for gabapentin?
- A. Drowsiness
- B. Hypertension
- C. Diarrhea
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Drowsiness. Gabapentin is known to cause central nervous system side effects, such as drowsiness, dizziness, and fatigue. The nurse should monitor the patient for signs of drowsiness as it can impact their daily activities and safety. Hypertension (B), diarrhea (C), and tachycardia (D) are not commonly associated with gabapentin use. Therefore, the nurse should primarily focus on monitoring for drowsiness as the most likely adverse effect.
A nurse is caring for a patient who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider? Which finding post-bowel resection should the nurse report?
- A. Soft, formed stools
- B. Abdominal distension
- C. Mild incisional pain
- D. Nausea
Correct Answer: B
Rationale: The correct answer is B: Abdominal distension. This finding could indicate a possible complication such as bowel obstruction or ileus post-bowel resection. The nurse should report this symptom promptly to the provider for further evaluation and intervention to prevent potential complications. Soft, formed stools (A) are expected after bowel resection, indicating bowel function is returning. Mild incisional pain (C) is common postoperatively and can be managed with pain medication. Nausea (D) can also be common after surgery but may require monitoring if persistent or severe. There are no additional choices provided, but it is essential for the nurse to prioritize reporting any unusual or concerning findings to ensure the patient's safety and well-being.
A nurse is preparing to administer Ringer's lactate via continuous IV infusion at a rate of 120 mL/hr. The manual IV tubing's drop factor is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? How many gtt/min for Ringer's lactate infusion?
Correct Answer: 120
Rationale: The correct answer is 120 gtt/min. To calculate the infusion rate in gtt/min, you first convert the hourly rate to minutes by dividing 120 mL/hr by 60 min/hr, which equals 2 mL/min. Then, multiply the mL/min by the drop factor of 60 gtt/mL to get the answer of 120 gtt/min. This ensures the correct amount of Ringer's lactate is delivered per minute. Other choices are incorrect because they do not follow the correct calculation steps or involve incorrect conversions, leading to inaccurate infusion rates.
A nurse is about to administer a daily dose of potassium chloride 20 mEq suspension orally. The available amount is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer? How many mL of potassium chloride should the nurse administer?
Correct Answer: 2
Rationale: To determine the amount of suspension needed, divide the desired dose (20 mEq) by the concentration (10 mEq/mL). 20 mEq ÷ 10 mEq/mL = 2 mL. This calculates the correct amount of 2 mL. Other choices are incorrect as they do not follow this calculation, leading to inaccurate dosing.