Nokea
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
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A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
- A. Good
- B. Excellent
- C. Fair
- D. Poor
Correct Answer: D
Rationale: The correct answer is D: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs. Prognosis is generally poor due to the advanced stage of the disease. Aggressive treatments can help manage symptoms and improve quality of life but are unlikely to cure the cancer. Discussing a poor prognosis with the client allows for realistic expectations and informed decision-making. Choices A, B, and C are incorrect as they suggest a better prognosis which is not typical for stage IV ovarian cancer.
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
- A. Keep the knee elevated above the heart at all times.
- B. Avoid physical therapy for 2 weeks.
- C. Apply ice to the affected area.
- D. Limit fluid intake to reduce swelling.
Correct Answer: C
Rationale: The correct answer is C: Apply ice to the affected area. Ice application helps reduce swelling and pain post-surgery. Keeping the knee elevated above the heart (A) is important, but not at all times as it can lead to other issues like blood pooling. Avoiding physical therapy for 2 weeks (B) is incorrect as early mobilization is crucial for recovery. Limiting fluid intake (D) is not recommended as hydration is essential for healing.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?
- A. Practice effective hand hygiene.
- B. Limit physical activity.
- C. Use antiseptic mouthwash.
- D. Avoid drinking water.
Correct Answer: A
Rationale: The correct answer is A: Practice effective hand hygiene. This is crucial in preventing transmission of hepatitis A, which is primarily spread through fecal-oral route. Handwashing with soap and water can remove the virus from hands. Limiting physical activity (B) and using antiseptic mouthwash (C) are not effective in preventing transmission. Avoiding drinking water (D) is not necessary unless the water source is contaminated.
A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
- A. Eye pain
- B. Sudden vision loss
- C. Decreased ability to perceive colors
- D. Excessive tearing
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (A) is not a typical symptom of cataracts. Sudden vision loss (B) is more commonly associated with conditions like retinal detachment. Excessive tearing (D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.