A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
- A. You will need to choose a family member to donate blood, instead of a friend.'
- B. This surgery has minimal blood loss, so you will not require a transfusion.'
- C. You can donate your own blood a few weeks prior to this surgery.'
- D. Using screened donor blood during a transfusion makes it unlikely that you would have an infusion reaction.'
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the best option because it addresses the client's concern about needing a blood transfusion during surgery by suggesting an effective proactive measure. Donating your own blood before surgery, known as autologous donation, ensures that you have your own blood available if needed, reducing the risk of transfusion reactions and complications. It allows for a personalized and safe option in case of blood loss during the procedure.
As for the other options:
A: This statement does not provide relevant information about blood transfusions.
B: This statement is inaccurate as total hip arthroplasty can result in significant blood loss requiring a transfusion.
D: While using screened donor blood reduces the risk of infusion reactions, it does not address the client's specific concern about needing a transfusion during surgery.
Therefore, option C is the most appropriate response as it directly addresses the client's query and offers a practical solution.
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A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
- A. Withdraw the medication from the ampule using a needleless system.
- B. Place a paper towel around the ampule's neck to break off the top with both hands.
- C. Dispose of the top of the ampule in a sharps container.
- D. Expel air into the ampule to aspirate air bubbles.
Correct Answer: B
Rationale: The correct answer is B: Place a paper towel around the ampule's neck to break off the top with both hands. This method helps prevent injury as the paper towel provides grip and protection. Breaking the ampule's top with both hands reduces the risk of glass shards. Using a needleless system (A) is not necessary for breaking an ampule. Disposing the top in a sharps container (C) is important, but it is not the immediate action for withdrawing medication. Expelling air into the ampule (D) is unnecessary and may introduce air bubbles into the medication.
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
- A. Obtain an ECG.
- B. Administer an opioid pain medication.
- C. Infuse IV fluids to maintain urine output at 75 mL/hr.
- D. Change dressings over the entrance and exit wounds.
Correct Answer: A
Rationale: The correct answer is A: Obtain an ECG. The first step in managing a client with an electrical shock injury is to assess for any cardiac complications, as electrical shock can cause arrhythmias. Obtaining an ECG will help the nurse identify any abnormal heart rhythms and determine the need for immediate intervention. Administering opioid pain medication (B) is not a priority as assessing the cardiac status takes precedence. Infusing IV fluids (C) is important but not the first priority. Changing dressings (D) can wait until the client's immediate medical needs are addressed.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/50 mmHg. Which of the following medications should the nurse administer?
- A. Naloxone
- B. Promethazine
- C. Acetylcysteine
- D. Flumazenil
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids like morphine, which can cause respiratory depression leading to bradypnea (slow breathing) and hypotension. In this case, the client's low respiratory rate and blood pressure indicate opioid overdose. Administering naloxone can help reverse the respiratory depression and stabilize the client's breathing and blood pressure.
Promethazine (B) is an antihistamine used for nausea and vomiting, not for opioid overdose. Acetylcysteine (C) is a mucolytic agent used for acetaminophen overdose. Flumazenil (D) is a benzodiazepine antagonist, not indicated for opioid overdose.