Nokea
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.
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The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by:
- A. Taking a warm shower upon awakening
- B. Applying ice packs to the joints
- C. Taking two aspirin before going to bed
- D. Going for an early morning walk
Correct Answer: A
Rationale: A warm shower reduces morning stiffness in rheumatoid arthritis by improving joint mobility and reducing inflammation.
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
- A. Intrauterine device
- B. Oral contraceptives
- C. Diaphragm
- D. Contraceptive sponge
Correct Answer: C
Rationale: The diaphragm is suitable for diabetic clients as it avoids hormonal effects that could impact glucose control.
The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
- A. Fluid volume deficit
- B. Alteration in body image
- C. Impaired oxygen exchange
- D. Alteration in elimination
Correct Answer: A
Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.
A client is admitted with a diagnosis of duodenal ulcer. A common complaint of the client with a duodenal ulcer is:
- A. Epigastric pain that is relieved by eating
- B. Weight loss
- C. Epigastric pain that is worse after eating
- D. Vomiting after eating
Correct Answer: A
Rationale: Duodenal ulcers typically cause epigastric pain that is relieved by eating due to buffering of gastric acid.