A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. As soon as the nurse can prepare the client and the administration set
- B. At 1200
- C. At 1300
- D. At 1400
Correct Answer: A
Rationale: The correct answer is A: As soon as the nurse can prepare the client and the administration set. It is important to start the infusion promptly to maximize the effectiveness of the blood transfusion. Delaying the infusion can lead to potential complications. Options B, C, and D are incorrect because they suggest delayed start times, which can be detrimental to the patient's health. Starting the infusion as soon as possible ensures that the patient receives the necessary blood components in a timely manner.
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A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with a ventilated ceiling fan
- C. A room with a window and curtains that close
- D. A shared room with other tuberculosis clients
Correct Answer: A
Rationale: The correct answer is A: A room with air exhaust directly to the outdoor environment. This is the appropriate room assignment for a client with active tuberculosis because it helps prevent the spread of airborne infectious particles. The air exhaust system ensures that contaminated air is not recirculated within the unit, reducing the risk of transmission to other patients and staff.
Choice B (A room with a ventilated ceiling fan) is incorrect because a ceiling fan does not provide sufficient ventilation to prevent the spread of tuberculosis.
Choice C (A room with a window and curtains that close) is also incorrect as it does not address the need for proper ventilation and containment of infectious particles.
Choice D (A shared room with other tuberculosis clients) is clearly incorrect as it would increase the risk of transmission among the clients.
In summary, the correct room assignment for a client with active tuberculosis should prioritize containment and ventilation to minimize the risk of spreading the infection to others.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Avoid reading for 1 week.
- C. Limit eye movements for 1 week.
- D. Do not bend forward at the waist for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This is important to prevent increased intraocular pressure that could lead to complications post cataract surgery. Lifting heavy objects can strain the eye and potentially disrupt the healing process.
B: Avoid reading for 1 week is incorrect as reading does not significantly impact intraocular pressure or the healing process post cataract surgery.
C: Limit eye movements for 1 week is incorrect as normal eye movements do not typically pose a risk to the surgical site after cataract extraction.
D: Do not bend forward at the waist for 1 week is incorrect as bending at the waist does not directly affect intraocular pressure or the healing of the eye after cataract surgery.
A client reports skin dryness, redness, and scaling after radiation. What should the nurse advise?
- A. Apply hydrating lotions.
- B. Scrub the area vigorously.
- C. Cover the area with adhesive bandages.
- D. Avoid moisturizing the skin.
Correct Answer: A
Rationale: The correct answer is A: Apply hydrating lotions. After radiation, skin can become dry and irritated. Hydrating lotions help to moisturize the skin and reduce dryness, redness, and scaling. They provide a protective barrier and promote skin healing. Advising the client to apply hydrating lotions is essential in maintaining skin integrity post-radiation.
Choice B: Scrubbing the area vigorously can further damage the skin and exacerbate irritation.
Choice C: Covering the area with adhesive bandages can trap moisture and lead to skin maceration.
Choice D: Avoiding moisturizing the skin can worsen dryness and discomfort.
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
- A. Avoid foods high in fat.
- B. Avoid foods high in carbohydrates.
- C. Eat a high-protein, low-fat diet.
- D. Increase intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in fat. Biliary colic is caused by gallstones, and high-fat foods can trigger gallbladder contractions leading to pain. Therefore, advising the client to avoid foods high in fat can help prevent biliary colic episodes. Choice B is incorrect as carbohydrates do not directly affect biliary colic. Choice C is incorrect because while a high-protein, low-fat diet may be beneficial for some conditions, it is not specifically recommended for biliary colic. Choice D is incorrect as increasing intake of high-fat foods can worsen symptoms.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.