Nokea
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
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A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client?
- A. Postmenopausal bleeding
- B. Weight loss
- C. Increased appetite
- D. Abnormal hair growth
Correct Answer: A
Rationale: The correct answer is A: Postmenopausal bleeding. Endometrial cancer commonly presents with postmenopausal bleeding as a key manifestation due to abnormal growth of the endometrial tissue. This occurs because the cancerous cells disrupt the normal shedding process of the endometrium, leading to bleeding after menopause. Weight loss (B) is often associated with advanced stages of cancer, but it is not a specific early manifestation of endometrial cancer. Increased appetite (C) and abnormal hair growth (D) are not typically associated with endometrial cancer.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Encourage the use of an incentive spirometer
- B. Administer oxygen therapy
- C. Provide early ambulation
- D. Monitor for chest pain
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
- A. Different apical and radial pulses.
- B. Shortness of breath on exertion.
- C. Excessive sweating.
- D. Systolic blood pressure of 150 mm Hg.
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (B), excessive sweating (C), and systolic blood pressure of 150 mm Hg (D) are not specific to atrial fibrillation and can occur in various conditions.
A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching?
- A. A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer.
- B. A CA 125 test is used to detect pregnancy.
- C. A CA 125 test is used to diagnose cervical cancer.
- D. A CA 125 test is used to screen for prostate cancer.
Correct Answer: A
Rationale: The correct answer is A: A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. This is because CA 125 is a biomarker that is commonly elevated in ovarian cancer patients. Monitoring CA 125 levels helps healthcare providers assess the effectiveness of treatment and detect any recurrence of the disease.
Choice B is incorrect because a CA 125 test is not used to detect pregnancy. Choice C is incorrect because a CA 125 test is not used to diagnose cervical cancer; it is primarily associated with ovarian cancer. Choice D is incorrect because a CA 125 test is not used to screen for prostate cancer; it is specific to ovarian cancer.