Nokea
A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
- A. Check the client's blood type with another nurse
- B. Verify the client's wristband identification
- C. Ensure the blood bag is labeled with the client's name
- D. Confirm the expiration date on the blood bag
- E. Match the blood type on the bag with the physician's order
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.
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A client with a history of asthma is prescribed albuterol (Proventil). The nurse should instruct the client to:
- A. Use the inhaler daily to prevent attacks.
- B. Rinse the mouth after each use.
- C. Use the inhaler during an acute attack.
- D. Stop the inhaler if heart palpitations occur.
Correct Answer: C
Rationale: Albuterol is a rescue inhaler used during acute asthma attacks to relieve bronchospasm.
A client with a history of depression is prescribed fluoxetine (Prozac). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Fluoxetine commonly causes insomnia, which should be reported to manage treatment.
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
- A. Physical therapy.
- B. Antibiotic therapy.
- C. Psychological therapy.
- D. Anti-inflammatory therapy.
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.
Neuroleptic malignant syndrome is suspected in a client who is prescribed an atypical antipsychotic medication. Which medication should the nurse prepare in anticipation of being prescribed to treat this adverse effect related to the use of this medication?
- A. Bromocriptine
- B. Protamine sulfate
- C. Enalapril maleate
- D. Phytonadione (vitamin K)
Correct Answer: A
Rationale: Bromocriptine is a dopamine pathway medication used in the treatment of neuroleptic malignant syndrome. Protamine sulfate is the antidote for heparin overdose. Vitamin K is the antidote for warfarin overdose. Enalapril maleate is an angiotensin-converting enzyme inhibitor and an antihypertensive that is used in the treatment of hypertension.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should instruct the client to take the medication:
- A. With meals
- B. At bedtime
- C. Before breakfast
- D. After exercise
Correct Answer: B
Rationale: Ranitidine, an H2 receptor blocker, is most effective when taken at bedtime to reduce nighttime acid production and promote ulcer healing.