Nokea
A nurse is providing dietary teaching to a client who has a new onset of vitamin B12 deficiency. Which of the following foods should the nurse encourage the client to include in their diet?(Select All that Apply)
- A. Steak
- B. Low fat milk
- C. Grilled salmon
- D. Green leafy vegetables
- E. Scrambled eggs
Correct Answer: A,B,C,E
Rationale: Steak, milk, salmon, and eggs are high in vitamin B12, suitable for addressing deficiency. Green leafy vegetables are not significant sources of B12, which is primarily found in animal products.
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A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?
- A. Exposure to radiation
- B. Family history
- C. Another type of cancer
- D. Genetic mutation
Correct Answer: A
Rationale: Exposure to high levels of radiation is a known risk factor for CML, as seen in historical data from atomic bomb survivors. Family history and other cancers are not significant risk factors, and the Philadelphia chromosome mutation is an acquired, not inherited, genetic factor.
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
- A. Hemolytic
- B. Allergic
- C. Febrile
- D. Bacterial
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.
A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?
- A. instruct the client to dig their heels into the bed to push themselves upwards.
- B. Assist the client with a trapeze to raise their body while staff assists with repositioning
- C. Have two to three staff members pull the client up in bed when needed.
- D. Elevate the head of the bed 90° for bedridden clients.
Correct Answer: B
Rationale: Using a trapeze reduces friction and shear forces during repositioning, preventing skin injuries. Other options increase friction or shear risks.
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Administer diphenhydramine, Administer an antibiotic, Administer furosemide, Stop transfusion
- B. Transfusion reaction, Transfusion associated circulatory overload, Acute extravasation
- C. Hives, Weight, Low back pain, Respiratory rate
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Anorexia and malnutrition
- B. Diarrhea and dehydration
- C. Bleeding from the gums
- D. Full body alopecia
Correct Answer: C
Rationale: Myelosuppression can cause thrombocytopenia, increasing bleeding risk, including from gums. Anorexia, diarrhea, and alopecia are chemotherapy side effects but not directly related to myelosuppression.