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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A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience retinal detachment. Which of the following statements should the nurse include in the teaching?
- A. Vision changes occur suddenly due to complete obstruction of aqueous humor outflow
- B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye
- C. Vision changes occur when the retina begins to breakdown and collect bits of debris
- D. Vision changes occur when the cloudy lens alters the passage of light through the eye
Correct Answer: B
Rationale: Retinal detachment occurs when the retina separates from its supporting tissues and blood vessels, leading to vision loss. Other options describe different eye conditions like glaucoma, macular degeneration, or cataracts.
A nurse is caring for a client with a chronic wound. Which of the following is a potential complication of a chronic wound?
- A. Electrolyte abnormalities
- B. Altered hemoglobin ATC
- C. Psychological distress
- D. Fluid volume overload
Correct Answer: C
Rationale: Chronic wounds can lead to significant emotional and psychological stress due to prolonged treatment, appearance issues, and limitations in activities. Electrolyte abnormalities are not typically a direct complication unless associated with severe infections or extensive fluid loss, which is uncommon. The wound itself does not directly alter hemoglobin A1C, which measures long-term blood glucose control. Fluid volume overload is not a direct complication of chronic wounds.
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 developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
- A. Keep family members aware of his condition.
- B. Talk with the client during wound care.
- C. Rotate nursing staff so he can have varied interactions.
- D. Assign assistive personnel to keep his room neat and clean.
Correct Answer: B
Rationale: Talking with the client during wound care builds trust, provides emotional support, and helps cope with pain and stress. Other options are less directly supportive emotionally.
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.