Nokea
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?
- A. Notifying the provider
- B. Stopping the transfusion
- C. Covering the client with a blanket
- D. Assessing the client's skin for a rash
Correct Answer: B
Rationale: Chills and back pain suggest a serious transfusion reaction, like hemolytic reaction. Stopping the transfusion immediately is the priority to prevent further complications.
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In reviewing a patient's complete blood count (CBC) results, the nurse notes a 'shift to the left.' What is the significance of these results?
- A. There is an elevated number of immature thrombocytes.
- B. There is an elevated number of immature neutrophils (bands),
- C. There is an elevated number of mature neutrophils (segs)
- D. There is an elevated number of mature erythrocytes
Correct Answer: B
Rationale: A 'shift to the left' indicates an increase in immature neutrophils (bands), often signaling acute infection or inflammation as the body releases more neutrophils to fight pathogens.
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.
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
- A. Massage over erythematous bony prominences.
- B. Implement a turning schedule every 4 hr.
- C. Keep the client's skin dry with powder.
- D. Minimize skin exposure to moisture.
- E. Use pillows to keep heels off the bed surface
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
- A. The first 2 min
- B. The final 2 min
- C. The final 15 min
- D. The first 15 min
Correct Answer: D
Rationale: Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for signs of a reaction, such as fever, chills, rash, or difficulty breathing.
A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
- A. Endolymph fluid provides protection to the structures of the inner ear.
- B. Sanguineous fluid provides protection to the structures of the inner ear.
- C. Aqueous humor provides protection to the structures of the inner ear.
- D. Vitreous humor provides protection to the structures of the inner ear.
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.