Nokea
A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?
- A. Prep the patient with pain medication.
- B. Notify the patient's family about the procedure via the telephone.
- C. Decrease the temperature of the blood to be given.
- D. Increase the temperature of the blood to be given.
Correct Answer: D
Rationale: Warming the blood will reduce the risk of additional cardiac arrhythmia.
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Which of the following instructions should the nurse give a client who will be undergoing mammography?
- A. Be sure to use underarm deodorant.
- B. Do not use underarm deodorant.
- C. Do not eat or drink after midnight.
- D. Have a friend drive you home.
Correct Answer: B
Rationale: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.
When a client has a chest drainage system in place, where should the system be placed?
- A. above the client's head
- B. at the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct Answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest so that the drainage flows out of the chest into the system. The remaining choices are too high and do not allow fluid to drain out of the chest.
Which of the following clients require airborne precautions?
- A. a client with fever, chills, vomiting, and diarrhea
- B. a client suspected of varicella (chickenpox)
- C. a client with abdominal pain and purpura
- D. a client diagnosed with AIDS
Correct Answer: B
Rationale: Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask.
Regardless of their practice area, nurses should be concerned with:
- A. All drug-resistant bacteria
- B. Microorganisms that are critical
- C. Transmission of microorganisms
- D. Overprescription of bacteriostatic drugs
Correct Answer: C
Rationale: Preventing microorganism transmission is a universal nursing concern to protect clients, families, and staff, achieved through asepsis and infection control practices.
In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms
- B. nutritional status
- C. bleeding problems
- D. availability of insulin
Correct Answer: C
Rationale: Bleeding problems are not typically associated with diabetes management. Assessing diabetic symptoms, nutritional status, and insulin availability are critical to ensure glycemic control in a disaster.