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A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
- A. 4 hr
- B. 2 hr
- C. 8 hr
- D. 6 hr
Correct Answer: A
Rationale: The total infusion time for packed RBCs should not exceed 4 hours to minimize the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications. Infusing beyond 4 hours increases this risk significantly.
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A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
- A. 1 cup canned black beans
- B. 8 a whole milk
- C. 1.5 oz raisins
- D. 8 or black tea
Correct Answer: A
Rationale: Black beans are high in iron, making them an excellent dietary choice for iron deficiency anemia. Milk can inhibit iron absorption due to calcium, raisins have less iron than beans, and tea contains tannins that reduce iron absorption.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
- A. Hemoglobin level
- B. Fluid intake
- C. Temperature
- D. Skin color
Correct Answer: C
Rationale: A baseline temperature is crucial to monitor for febrile reactions during transfusion. A significant rise indicates a reaction requiring intervention. Other data are less immediate.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. increased heart rate
- B. Increase hematocrit
- C. increased blood pressure
- D. Increased temperature
- E. increased respiratory rate
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.
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.