Nokea
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.
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A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?
- A. Administer an antiemetic.
- B. Prepare to insert a nasogastric (NG) tube.
- C. Collect data regarding recent client stressors.
- D. Place the client in a modified Trendelenburg position.
Correct Answer: D
Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.
A client with a history of seizures is prescribed phenytoin (Dilantin). Which laboratory value should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Phenytoin can cause hepatotoxicity, so liver function tests should be monitored regularly to detect potential liver damage early.
A client with a history of depression is prescribed bupropion (Wellbutrin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Seizures.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bupropion lowers the seizure threshold, and seizures are a serious side effect requiring immediate reporting.
A new mother was administered methylergonovine maleate intramuscularly after delivery. The nurse understands that this medication was administered for which action?
- A. Decrease uterine contractions.
- B. Prevent postpartum hemorrhage.
- C. Maintain a normal blood pressure.
- D. Reduce the amount of lochia drainage.
Correct Answer: B
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The first dose is usually administered intramuscularly, and then if it needs to be continued, it is given by mouth. It increases the strength and frequency of contractions and may elevate blood pressure. There is no relationship between the action of this medication and lochia drainage.
When a child is able to grasp the idea that a ball continues to exist even though his parent placed the ball under a hat, the child is in which of the following stages in the development of logical thinking, according to Piaget?
- A. Sensorimotor.
- B. Preoperational.
- C. Concrete operations.
- D. Formal operations.
Correct Answer: A
Rationale: Object permanence, understanding that objects exist when out of sight, develops during the sensorimotor stage (birth to 2 years) per Piaget's theory.