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A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Generalized urticaria.
- B. Distended jugular veins.
- C. Blood pressure 184/92 mm Hg.
- D. Bilateral flank pain.
Correct Answer: A
Rationale: The correct answer is A: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. The release of histamine during the reaction causes itching and skin rash. Distended jugular veins (B) are more indicative of fluid overload or heart failure. Blood pressure of 184/92 mm Hg (C) is elevated but not specific to an allergic reaction. Bilateral flank pain (D) may suggest kidney issues or musculoskeletal problems, not necessarily related to an allergic reaction.
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A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
- A. 730
- B. 745
- C. 815
- D. 720
Correct Answer: A
Rationale: The correct answer is A: 730. After administering regular insulin, it is crucial to ensure the client receives breakfast within 30 minutes to an hour to prevent hypoglycemia. Breakfast at 730 allows adequate time for the insulin to start working before the client consumes food. Choice B (745) is too late, increasing the risk of hypoglycemia. Choice C (815) is too delayed and may cause an imbalance in blood sugar levels. Choice D (720) is too soon after administering insulin, increasing the risk of hypoglycemia.
A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
- A. Vesicles on the skin
- B. Respiratory failure
- C. Flu-like symptoms
- D. Coughing of blood
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Inhalation anthrax primarily affects the respiratory system, causing symptoms such as difficulty breathing, cough, and chest discomfort. Respiratory failure can occur in severe cases. Vesicles on the skin (A) are not typically associated with inhalation anthrax. Flu-like symptoms (C) are nonspecific and can be seen with various infections. Coughing of blood (D) is not a common symptom of inhalation anthrax. Therefore, the most indicative finding of possible exposure to inhalation anthrax is respiratory failure.
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
- A. Family history of cardiac disease.
- B. Increasing age.
- C. Diagnosis of diabetes mellitus.
- D. Cigarette smoking.
Correct Answer: D
Rationale: The correct answer is D: Cigarette smoking. Smoking is a modifiable risk factor for cardiovascular disease as individuals can quit smoking to reduce their risk. Family history (A) and increasing age (B) are non-modifiable risk factors. Diabetes (C) is a risk factor but not modifiable in this context. Other choices not provided.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.
A nurse is preparing to administer fluoxetine 30 mg PO daily to a client. The amount available is fluoxetine 10 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Correct Answer: 3
Rationale: The correct answer is 3 tablets. To achieve a total of 30 mg, the nurse should administer 3 tablets of 10 mg each (10 mg x 3 = 30 mg). Other choices are incorrect because: A) 1 tablet is not enough to reach 30 mg, B) 2 tablets only add up to 20 mg, C) 4 tablets exceed the required dose, D) 5 tablets exceed the required dose, E) 6 tablets exceed the required dose, F) 7 tablets exceed the required dose, G) 8 tablets exceed the required dose.