Nokea
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 nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?
- A. Request an interpreter of a different sex from the client
- B. Request a family member or friend to interpret information for the client
- C. Direct attention toward the interpreter when speaking to the client
- D. Review the facility policy about the use of an interpreter
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.
A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?
- A. Flush the tube with 30 mL of sterile water before each feeding
- B. Administer the feeding using a large-bore syringe
- C. Keep the head of the bed elevated to 15 degrees
- D. Replace the feeding bag every 24 hours
Correct Answer: A
Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.
A nurse is caring for a client who has cirrhosis. Which of the following laboratory findings should the nurse expect?
- A. Increased bilirubin levels
- B. Decreased albumin levels
- C. Increased prothrombin time
- D. Decreased serum glucose levels
Correct Answer: A
Rationale: Corrected Rationale: Increased bilirubin levels are expected in clients with cirrhosis due to impaired liver function. Elevated bilirubin levels are commonly seen in cirrhosis as the liver's ability to process bilirubin is compromised. Decreased albumin levels and increased prothrombin time are also associated with cirrhosis, but the most specific finding related to liver dysfunction among the choices provided is increased bilirubin levels. Decreased serum glucose levels are not typically associated with cirrhosis.
A client requests the creation of a living will. Which of the following actions should the nurse take?
- A. Schedule a meeting between the hospital ethics committee and the client
- B. Evaluate the client's understanding of life-sustaining measures
- C. Determine the client's preferences about post-mortem care
- D. Request a conference with the client's family
Correct Answer: B
Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.
A client with a new diagnosis of Graves' disease and a prescription for propylthiouracil (PTU) is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should report a sore throat to my provider.
- B. I will need to take this medication for the rest of my life.
- C. This medication increases my risk for infection.
- D. This medication decreases my appetite.
Correct Answer: C
Rationale: The correct answer is C because propylthiouracil (PTU) can increase the risk of infection. Therefore, the client should be aware that this medication may compromise their immune system, making them more susceptible to infections. Reporting any signs of infection promptly to the provider is crucial for timely intervention and management. Choices A, B, and D are incorrect because reporting a sore throat, assuming lifelong medication intake, or experiencing decreased appetite are not directly related to the medication's side effects or risks.