Nokea
The client who received 50 mL from a unit of whole blood has low back pain. In response to this client’s symptom, which action should be taken by the nurse first?
- A. Reposition the client.
- B. Assess the pain further.
- C. Administer an analgesic.
- D. Stop the blood transfusion.
Correct Answer: D
Rationale: A. Repositioning focuses on treating the client’s back pain and not on the blood transfusion, which could be the cause of the back pain. B. Further assessment should occur after stopping the blood transfusion. C. The client may need an analgesic for pain control, but this should occur after stopping the blood transfusion. D. Low back pain is a symptom of a potentially life-threatening acute hemolytic reaction. The pain is caused from agglutination of RBCs in the kidneys and renal vasoconstriction. Hemolytic reactions occur most often within the first 50 mL of the infusion.
You may also like to solve these questions
The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin?
- A. Assess the client’s oral mucosa.
- B. Assess the client’s metatarsals.
- C. Assess the client’s capillary refill time.
- D. Assess the sclera of the client’s eyes.
Correct Answer: A
Rationale: Oral mucosa (A) is the best site to assess cyanosis in dark skin, showing dusky color. Metatarsals (B) and sclera (D) are less reliable, and capillary refill (C) assesses perfusion.
Which interrelated psychological concept is priority for the nurse caring for a client diagnosed with leukemia?
- A. Comfort.
- B. Stress.
- C. Grieving.
- D. Coping.
Correct Answer: C
Rationale: Leukemia’s life-threatening nature makes grieving (C) a priority, addressing loss of health. Comfort (A), stress (B), and coping (D) are secondary.
The nurse is teaching self-care measures to the client hospitalized with HP. Which measures should the nurse plan to include?
- A. “Use dental floss daily after brushing your teeth.”
- B. “Use only an electric razor when you need to shave.”
- C. “Remove throw rugs in your home and avoid clutter.”
- D. “Increase fiber in your diet and drink plenty of liquids.”
- E. “Keep appointments for monthly platelet transfusions.”
Correct Answer: B, C, D
Rationale: Dental floss can traumatize the gums and increase the risk for bleeding. B. Because the client is at risk for bleeding due to low platelet counts, measures to decrease the risk of bleeding should be implemented, such as using an electric razor. C. Throw rugs and clutter increase the risk for falls with subsequent bleeding. D. Fiber and fluids help prevent constipation. Constipation can lead to hemorrhoids and increase the risk for bleeding. E. Platelet transfusions are usually avoided because the person’s antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed.
Which of the following would be the most appropriate snack for a client who has iron deficiency anemia?
- A. Half of a grapefruit
- B. A carrot raisin salad
- C. A cup of yogurt
- D. Apple slices and cheese
Correct Answer: B
Rationale: Carrot raisin salad contains raisins, which are a good source of iron, making it appropriate for iron deficiency anemia.
The client asks the nurse to look at a lesion on the client’s body. Which characteristics should prompt the nurse to consider that the client may have a basal cell carcinoma (BCC)?
- A. Nodular in appearance, depression in the center, and has a “pearly” characteristic
- B. Irregular color, surface, and border, less than one centimeter, and appears eroded
- C. Dry, hyperkeratotic scaly-like papule and has the appearance similar to a wart
- D. Vesiculopustular lesion with a thick, honey-colored crust and pruritic in nature
Correct Answer: A
Rationale: BCC is nodular and ulcerative. Clinical manifestations include small, slowly enlarging papule; borders are translucent or “pearly” with overlying telangiectasia; erosion, ulceration, and depression of center. B. Clinical manifestations of malignant melanoma (not BCC) include irregular color, surface, and border; variegation of color including red, white, blue, black, gray, brown; flat or elevated; eroded or ulcerated. C. Actinic keratosis (not BCC) is characterized by being horny and “wartlike.” D. Impetigo is characterized by thick, honey-colored crusts and is treated with antibiotics and topical treatment.