Nokea
A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
- A. Endolymph fluid provides protection to the structures of the inner ear.
- B. Sanguineous fluid provides protection to the structures of the inner ear.
- C. Aqueous humor provides protection to the structures of the inner ear.
- D. Vitreous humor provides protection to the structures of the inner ear.
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.
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A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
- A. Hemoglobin level
- B. Fluid intake
- C. Temperature
- D. Skin color
Correct Answer: C
Rationale: A baseline temperature is crucial to monitor for febrile reactions during transfusion. A significant rise indicates a reaction requiring intervention. Other data are less immediate.
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
- A. 4 hr
- B. 2 hr
- C. 8 hr
- D. 6 hr
Correct Answer: A
Rationale: The total infusion time for packed RBCs should not exceed 4 hours to minimize the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications. Infusing beyond 4 hours increases this risk significantly.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Scatter rugs are present in the kitchen,
- B. Handrails are present in the bathroom.
- C. Electrical cords are placed along the walls.
- D. Uses a microwave for cooking.
Correct Answer: A
Rationale: Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment. Handrails provide support and help prevent falls, making them a safety feature, not a risk. Electrical cords placed along walls reduce tripping hazards. A microwave is generally safer than a stove, reducing the risk of burns and fires.
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.