Nokea
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
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Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm?
- A. Ozone
- B. Nitrous oxide
- C. Carbon monoxide
- D. Carbon dioxide
Correct Answer: C
Rationale: Carbon monoxide detectors are widely available, inexpensive, and similar to smoke alarms, detecting a colorless, odorless gas that poses a significant health risk. Ozone, nitrous oxide, and carbon dioxide detectors are less common in homes.
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
The nurse is starting a peripheral vascular access device for a client. The nurse inserted the device into the vein and observed a flashback of blood in the chamber. The nurse should then
- A. Advance the VAD approximately 3 inches (7.62 cm) into the vein and loosen the stylet.
- B. Remove the stylet and secure the catheter using a transparent dressing.
- C. Advance the VAD approximately 1/4 inch (0.6 cm) into the vein and loosen the stylet.
- D. Remove the stylet and release the tourniquet.
Correct Answer: D
Rationale: After observing a blood flashback, the nurse should remove the stylet and release the tourniquet to prevent hematoma formation, then secure the catheter. Advancing further risks vein damage or dislodgement, and securing without releasing the tourniquet is incorrect.
The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take?
- A. Place a box of disposable respirators inside the client's room.
- B. Remove alcohol-based sanitizers from the client's room.
- C. Assign the client to a private room with a positive airflow.
- D. Remove the portable fan from the client's bedside table.
Correct Answer: D
Rationale: Removing the portable fan prevents the spread of airborne Mycobacterium tuberculosis. A negative airflow room is required, and respirators should be stored outside the room.
The nurse is preparing to administer an enema to a client who is experiencing constipation. Place the following actions in the order listed:
- A. Lubricate the tip of the enema applicator
- B. Remove the applicator after the solution has been infused.
- C. Explain the procedure and help the client lie on the left side with their knees flexed and back toward you
- D. Release clamp
- E. Insert into the client's rectum
- F. Fill the enema bag, prime, and clamp tubing
Correct Answer: F,A,C,E,D,B
Rationale: The correct order is: fill and prime bag (F), explain and position client (C), lubricate tip (A), insert tube (E), release clamp (D), remove applicator (B). This ensures safe administration.