Nokea
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
- A. Packed RBCS
- B. Fresh frozen plasma
- C. Recombinant
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Recombinant factor VIII is a synthetic form of the clotting factor deficient in hemophilia A, used to increase factor VIII levels before procedures to prevent excessive bleeding. Packed RBCs treat anemia, not clotting deficiencies. Fresh frozen plasma contains all clotting factors but is less targeted than recombinant factor VIII. Prophylactic antibiotics prevent infection, not bleeding.
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A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
- A. Check the client's vital signs.
- B. Cover the wound with a moist, sterile gauze dressing.
- C. Assess the client's pain level.
- D. Obtain a culture and sensitivity of the wound drainage
Correct Answer: B
Rationale: Covering the wound with a moist, sterile dressing is the priority to protect it from infection and manage drainage, preventing further contamination and supporting healing.
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
- A. To place my leg under a heat lamp every 3 hours
- B. Keep a heating pad on the calf of my right leg when I am lying down.
- C. wrap a warm, wet towel around my right calf every 4 hours.
- D. will sit on the side of the tub and soak my right leg two times every day.
Correct Answer: C
Rationale: A warm, wet towel provides moist heat, promoting blood flow and healing in cellulitis without risking burns or uneven heating from other methods.
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.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Slurred speech
- B. Confusion
- C. Pain
- D. Fatigue
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
- A. Stop the infusion of blood,
- B. Inform the provider.
- C. Obtain a urine specimen.
- D. Notify the laboratory.
Correct Answer: A
Rationale: Symptoms suggest an acute hemolytic transfusion reaction, a life-threatening emergency. Stopping the transfusion immediately is critical to prevent further reaction and hemolysis.