Nokea
An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply.
- A. The victim with chemical spills on both arms.
- B. The victim with third-degree burns of both legs.
- C. The victim with first-degree burns of both hands.
- D. The victim in respiratory distress.
- E. The victim who inhaled smoke.
Correct Answer: A,B,D,E
Rationale: Victims with chemical burns, third-degree burns, respiratory distress, or smoke inhalation require specialized care at a burn center due to the severity and potential complications of these injuries.
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A client with bladder cancer receives intravesical chemotherapy. The nurse should:
- A. Monitor for hematuria.
- B. Restrict fluids.
- C. Administer pain medication.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Hematuria is a potential side effect of intravesical chemotherapy, requiring monitoring.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
The nurse is preparing a client for a paracentesis. The nurse should:
- A. Have the client void immediately before the procedure.
- B. Place the client in a side-lying position.
- C. Initiate an I.V. line to administer sedatives.
- D. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.
Correct Answer: A
Rationale: Voiding before paracentesis (A) prevents bladder injury during the procedure. Side-lying (B) is incorrect; upright is preferred. IV sedatives (C) are not routine, and NPO status (D) is unnecessary.
A 58-year-old male is going to have chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following?
- A. Immunotherapy affects all rapidly dividing cells.
- B. The molecular structure of the DNA is altered.
- C. Cancer cells are susceptible to drug toxins.
- D. Chemotherapy encourages cancer cells to divide.
Correct Answer: B
Rationale: Chemotherapy often works by altering the DNA structure of cancer cells, inhibiting their ability to replicate and leading to cell death.
The nurse in the infusion center is caring for a 27-year-old male.
Item 1 of 1
• Nurses' Notes
1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
• Orders
• Infuse 1 unit of packed red blood cells
• Medical History
• Sickle cell anemia
• Depression
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
- A. pause the transfusion and discontinue the vascular access device,discontinue the packed red blood cell transfusion and return it to the blood bank
,start a new 20-gauge vascular access device in the opposite extremity,pause the transfusion obtain an order for acetaminophen - B. febrile transfusion reaction,infiltration at the vascular access device
hemolytic transfusion reaction,circulatory overload - C. discomfort and swelling at vascular access site,hemoglobin and hematocrit,temperature,blood pressure
Correct Answer:
Rationale: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling.
The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL.
It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration.
The blood pressure does not require monitoring because it does not show evidence of circulatory overload.