Nokea
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification band
- B. Verify the provider's prescription
- C. Prime the IV tubing with 0.9% sodium chloride
- D. Obtain the client's vital signs
Correct Answer: A
Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.
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A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?
- A. PT 28 seconds
- B. INR 1.2
- C. aPTT 40 seconds
- D. Fibrinogen 350 mg/dL
Correct Answer: B
Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.
A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?
- A. Denial
- B. Bargaining
- C. Acceptance
- D. Anger
Correct Answer: B
Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'
A client is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia?
- A. Constipation
- B. Numbness and tingling of the fingers
- C. Increased thirst
- D. Frequent urination
Correct Answer: B
Rationale: Numbness and tingling of the fingers are classic signs of hypocalcemia, a condition that may result from inadvertent damage to the parathyroid glands during a thyroidectomy. These symptoms occur due to decreased levels of calcium in the bloodstream affecting nerve function. Choices A, C, and D are not typical manifestations of hypocalcemia. Constipation is more associated with hypercalcemia, increased thirst can be seen in diabetes or dehydration, and frequent urination is a symptom more commonly linked to conditions like diabetes or urinary tract issues.
A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?
- A. Keep track of calorie intake for food and beverages.
- B. Provide a low-protein, high-carbohydrate diet.
- C. Schedule meals at 6-hour intervals.
- D. Provide a high-protein, high-calorie diet.
Correct Answer: D
Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.
A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?
- A. INR 2.0
- B. Platelet count 150,000/mm3
- C. aPTT 60 seconds
- D. WBC count 8,000/mm3
Correct Answer: C
Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.