Nokea
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
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A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs.
Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided.
In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.
Which of the ff vessels is often used for grafting?
- A. The basic and cephalic veins in the arm
- B. The internal mammary and internal thoracic arteries in the chest
- C. The saphenous vein in the leg
- D. The radial artery in the arm
Correct Answer: B
Rationale: The correct answer is B because the internal mammary and internal thoracic arteries in the chest are commonly used for grafting due to their size, durability, and long-term patency. These arteries have a better track record for successful grafting procedures compared to the other options. The basic and cephalic veins in the arm (Option A) are typically used for venous procedures, not arterial grafting. The saphenous vein in the leg (Option C) is also commonly used for grafting, but the internal mammary and internal thoracic arteries are preferred for their better outcomes. The radial artery in the arm (Option D) is less commonly used for grafting compared to the internal mammary and internal thoracic arteries.
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (A) is not ideal as healthy fats are needed. Low-sodium (B) is not necessary unless there is concurrent heart failure. Bland soft diet (C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care.
Incorrect choices:
A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.