Nokea
During a blood transfusion, which sign or symptom should prompt the healthcare provider to immediately stop the transfusion?
- A. Slight increase in blood pressure
- B. Elevated temperature and chills
- C. Mild nausea
- D. Slight headache
Correct Answer: B
Rationale: The correct answer is B: Elevated temperature and chills. These symptoms are indicative of a transfusion reaction, which can be severe and life-threatening. It is crucial to stop the transfusion immediately and notify the healthcare provider for further assessment and management. Elevated temperature and chills are classic signs of a transfusion reaction, specifically indicating a possible febrile non-hemolytic reaction. Choice A, a slight increase in blood pressure, is not typically a reason to stop a transfusion unless it is a significant sudden increase. Mild nausea (Choice C) and a slight headache (Choice D) are common side effects of blood transfusions and are not primary indicators of a transfusion reaction that require immediate cessation of the transfusion.
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Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?
- A. How much exercise did the child have today?
- B. Did the child perform a finger stick?
- C. When did the child last urinate?
- D. Has the child eaten recently?
Correct Answer: B
Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.
A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?
- A. Avoid crossing your legs at the knees or ankles.
- B. Do not sleep on the side of the hip that was operated on.
- C. Sit in high chairs and keep your knees higher than your hips.
- D. Do not bend forward at the waist to pick up objects.
Correct Answer: A
Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.
A client reports being able to swallow only small bites of solid food and liquids for the last 3 months. The PN should assess the client for what additional information?
- A. Past traumatic injury to the neck
- B. Daily consumption of hot beverages
- C. History of alcohol or tobacco use
- D. Daily dietary intake of roughage
Correct Answer: C
Rationale: The correct answer is C: History of alcohol or tobacco use. A history of alcohol or tobacco use is significant as both are risk factors for esophageal cancer or other esophageal disorders that could cause difficulty swallowing (dysphagia). This information helps in evaluating the underlying cause of the symptom. Choices A, B, and D are less relevant in this context. While a past traumatic injury to the neck could potentially cause swallowing difficulties, given the chronic nature of the symptom in this case, it is more important to focus on potential risk factors associated with esophageal disorders like alcohol and tobacco use. Daily consumption of hot beverages and daily dietary intake of roughage are less likely to be directly related to the client's current swallowing issue.
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement?
- A. Stimulate the infant to cry
- B. Give oxygen by positive pressure
- C. Suction the oral and nasal passages
- D. Turn the infant onto the right side
Correct Answer: C
Rationale: Suctioning the oral and nasal passages is the correct immediate intervention in this scenario. Regurgitation leading to cyanosis indicates a potential airway obstruction, which requires prompt action to clear. Stimulating the infant to cry (Choice A) may not address the underlying issue of airway obstruction. Giving oxygen by positive pressure (Choice B) can be beneficial, but clearing the airway obstruction takes precedence. Turning the infant onto the right side (Choice D) does not directly address the need to clear the airway.
What is the primary function of hemoglobin in red blood cells?
- A. To transport oxygen from the lungs to body tissues
- B. To protect the body from infections
- C. To help in blood clotting
- D. To regulate body temperature
Correct Answer: A
Rationale: The primary function of hemoglobin in red blood cells is to transport oxygen from the lungs to body tissues and return carbon dioxide from the tissues to the lungs. Hemoglobin binds to oxygen in the lungs and releases it in the body's tissues. Choice B is incorrect because hemoglobin is not involved in protecting the body from infections. Choice C is incorrect because blood clotting is mainly facilitated by platelets and clotting factors, not hemoglobin. Choice D is incorrect because the regulation of body temperature is mainly controlled by processes like sweating and shivering, not by hemoglobin.