Nokea
A patient has suffered a left CVA and has developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema and the skin is intact. The nurse should score the patient as having which of the following?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: A
Rationale: Erythema with the skin intact can indicate a Stage I pressure ulcer.
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Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: Normal saline (0.9% sodium chloride) is isotonic and safe for flushing IV lines before and after blood administration, preventing cell lysis or clotting.
Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to:
- A. supplement vitamin pills.
- B. balance body molecules.
- C. cure many diseases.
- D. help improve body defenses.
Correct Answer: D
Rationale: Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases.
A patient has recently been prescribed (Norvasc). Which of the following side effect/s should the patient specifically watch out for?
- A. Hypotension and Angina
- B. Hypertension
- C. Lower extremity edema
- D. Peripheral sensory loss and SOB
Correct Answer: A
Rationale: Both angina and hypotension are associated with Norvasc's side effects.
A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. Packed red blood cells
- B. Platelets
- C. Plasma
- D. Granulocytes
Correct Answer: A
Rationale: Packed red blood cells require cross-matching due to their antigens and antibodies, unlike platelets, plasma, or granulocytes, which do not contain red cells.
Who should receive the hepatitis A vaccine?
- A. children who are 18 months of age
- B. infants, who should receive the vaccination at birth
- C. people who travel to other countries
- D. individuals who might come into contact with blood
Correct Answer: C
Rationale: Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.