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A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification bracelet.
- B. Obtain the client's vital signs.
- C. Initiate the transfusion slowly over the first 15 minutes.
- D. Verify the client's blood type and Rh factor.
Correct Answer: D
Rationale: The correct answer is to verify the client's blood type and Rh factor first before administering blood. This is crucial to ensure compatibility and prevent transfusion reactions. Checking the client's identification bracelet (Choice A) is important but should come after verifying blood type. Obtaining vital signs (Choice B) and initiating the transfusion slowly (Choice C) are important steps but verifying blood type is the priority to ensure safe blood administration.
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A client is experiencing a panic attack. Which of the following actions should the nurse take first?
- A. Instruct the client to take deep, slow breaths.
- B. Administer an anti-anxiety medication.
- C. Remain with the client and offer reassurance.
- D. Encourage the client to use distraction techniques.
Correct Answer: C
Rationale: During a panic attack, the priority action for the nurse is to remain with the client and offer reassurance. This helps provide a sense of safety and security, which can aid in reducing the client's anxiety. Instructing the client to take deep, slow breaths (Choice A) can be beneficial but should come after providing immediate support. Administering medication (Choice B) should not be the first intervention unless deemed necessary by the healthcare provider. Encouraging distraction techniques (Choice D) may not be as effective initially as providing direct support and reassurance.
A nurse is caring for a client who has osteoarthritis. Which of the following actions should the nurse take?
- A. Apply heat to inflamed joints
- B. Provide passive range-of-motion exercises
- C. Encourage prolonged use of NSAIDs
- D. Apply cold packs to the joints
Correct Answer: A
Rationale: Corrected Rationale: Applying heat to inflamed joints can help relieve pain in clients with osteoarthritis. Heat therapy can help improve blood circulation, relax muscles, and reduce stiffness. Choice B, providing passive range-of-motion exercises, may be beneficial for joint mobility but is not the first-line intervention for pain relief in osteoarthritis. Choice C, encouraging prolonged use of NSAIDs, should be done cautiously due to potential side effects and should be guided by a healthcare provider. Choice D, applying cold packs to the joints, is not recommended for osteoarthritis as cold therapy can worsen stiffness and discomfort in this condition.
A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
- A. Instill 500 ml of solution through the NG tube
- B. Insert a large-bore NG tube
- C. Use a cold irrigation solution
- D. Instruct the client to lie on his right side
Correct Answer: B
Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.
A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
- A. Chlamydia
- B. Human papillomavirus
- C. Candidiasis
- D. Herpes simplex virus
Correct Answer: A
Rationale: Chlamydia is the correct answer. Chlamydia is a sexually transmitted infection that is considered a nationally notifiable infectious disease, meaning healthcare providers are required to report cases to public health authorities. Reporting such cases is crucial for disease surveillance and implementing appropriate control measures. Human papillomavirus, Candidiasis, and Herpes simplex virus are not nationally notifiable infectious diseases and do not require mandatory reporting to the state health department.
A nurse is assessing a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate 110/min.
- B. Temperature of 37.4°C (99.3°F).
- C. Respiratory rate of 18/min.
- D. Urine output of 20 mL/hr.
Correct Answer: D
Rationale: A urine output of 20 mL/hr is below the expected range and indicates potential renal failure, requiring immediate intervention. In postoperative patients, a urine output less than 30 mL/hr suggests inadequate renal perfusion, a concern that needs prompt attention to prevent renal complications. The heart rate of 110/min, temperature of 37.4°C (99.3°F), and respiratory rate of 18/min are within normal ranges for a postoperative client and do not indicate immediate issues.