Nokea
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 correct answer because autologous blood donation involves donating your own blood before surgery to be transfused back to you if needed. This reduces the risk of transfusion reactions and ensures a compatible blood match. Option A is incorrect because family members are not typically required to donate blood for surgery. Option B is incorrect as total hip arthroplasty can involve significant blood loss. Option D is incorrect as even with screened donor blood, transfusion reactions can still occur.
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A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.
- B. I can put the tablet against my cheek and gum.
- C. I should chew the tablet before I swallow it.
- D. I should take this medication as soon as the pain begins.
Correct Answer: D
Rationale: The correct answer is D: "I should take this medication as soon as the pain begins." This is correct because nitroglycerin is a rapid-acting medication used to relieve chest pain associated with angina. Taking it at the onset of chest pain helps dilate blood vessels and improve blood flow to the heart muscle.
Choice A is incorrect because taking another dose after 2 minutes could lead to overdose and hypotension. Choice B is incorrect as the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because nitroglycerin should not be chewed but allowed to dissolve under the tongue.
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Bull's eye lesion
- C. Esophagitis
- D. Tophi
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus commonly affects the joints, leading to inflammation and pain. This is known as lupus arthritis. Other choices are incorrect: B (Bull's eye lesion) is associated with Lyme disease, C (Esophagitis) is inflammation of the esophagus which is not a common manifestation of lupus, and D (Tophi) are uric acid crystal deposits seen in gout, not lupus.
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Gag reflex
- B. Warmth of extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample
- B. Check the clients' vital signs
- C. Stop the infusion
- D. Administer oxygen to the client
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interact with this medication?
- A. Orange juice.
- B. Kale.
- C. Beef stew.
- D. Yogurt.
Correct Answer: B
Rationale: The correct answer is B: Kale. Kale is high in vitamin K, which can interfere with the anticoagulant effects of warfarin by increasing the clotting factors in the blood, leading to a decreased INR. It is important for patients on warfarin to maintain a consistent intake of vitamin K-rich foods to ensure their INR remains within the therapeutic range. Orange juice (A), beef stew (C), and yogurt (D) do not significantly interact with warfarin. A summary of why they are incorrect: Orange juice does not have a direct interaction with warfarin. Beef stew does not contain significant amounts of vitamin K. Yogurt is not a high vitamin K food.