Nokea
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 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. Take a warm shower every day.
- C. Resume regular activities immediately.
- D. Avoid all physical activity for the next month.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This instruction is crucial after a cataract extraction to prevent any strain on the eye during the initial healing period. Lifting heavy objects can increase intraocular pressure and potentially lead to complications. Choice B (Take a warm shower every day) is not directly related to post-operative care for a cataract extraction. Choice C (Resume regular activities immediately) is incorrect as the client should avoid strenuous activities, including heavy lifting, to allow proper healing. Choice D (Avoid all physical activity for the next month) is overly restrictive and unnecessary. It's important to provide specific, clear, and relevant instructions to support the client's recovery.
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Place the client in Trendelenburg position.
- C. Apply a warm compress to the wound.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
A nurse teaches a client with vulvodynia about self-care. What statement indicates understanding?
- A. I should use scented soaps.
- B. I should avoid the use of any lubricants.
- C. I should wear tight synthetic underwear.
- D. I should use hot baths frequently.
Correct Answer: B
Rationale: The correct answer is B. Clients with vulvodynia should avoid the use of any lubricants to prevent irritation and exacerbation of symptoms. Lubricants can contain chemicals or fragrances that can further irritate the sensitive skin in the vulvar area. Choosing products specifically designed for sensitive skin or recommended by a healthcare provider is crucial. Using lubricants can worsen symptoms and discomfort.
Avoiding scented soaps (choice A) is important as well because fragrances can also irritate the vulvar area. Wearing tight synthetic underwear (choice C) can trap moisture and heat, leading to increased irritation. Using hot baths frequently (choice D) can also worsen symptoms by further irritating the sensitive skin.
A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
- A. Eye pain
- B. Sudden vision loss
- C. Decreased ability to perceive colors
- D. Excessive tearing
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (A) is not a typical symptom of cataracts. Sudden vision loss (B) is more commonly associated with conditions like retinal detachment. Excessive tearing (D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.
A nurse is planning a teaching session about hysterosalpingography for a client who has a diagnosis of infertility. The nurse should include which of the following information in the teaching plan?
- A. The client might experience shoulder pain following the procedure.
- B. The client might experience nausea and vomiting after the procedure.
- C. The client will need to stay in bed for 24 hours post-procedure.
- D. The client should avoid drinking fluids before the procedure.
Correct Answer: A
Rationale: The correct answer is A: The client might experience shoulder pain following the procedure. This is because hysterosalpingography involves the injection of contrast dye into the uterus and fallopian tubes, which can cause referred pain to the shoulder due to irritation of the diaphragm. This information is crucial for the client to be aware of potential side effects.
The other choices are incorrect:
B: The client might experience nausea and vomiting after the procedure - This is not a common side effect of hysterosalpingography.
C: The client will need to stay in bed for 24 hours post-procedure - There is no requirement for prolonged bed rest after the procedure.
D: The client should avoid drinking fluids before the procedure - In fact, it is recommended to drink plenty of fluids before the procedure to help flush out the contrast dye.