Nokea
The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse implement?
- A. Call the HCP to question the order because blood must infuse within four (4) hours.
- B. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate.
- C. Notify the laboratory to split each unit into half-units and infuse each half for four (4) hours.
- D. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.
Correct Answer: A
Rationale: Blood must infuse within 4 hours to prevent bacterial growth; 8-hour infusion (B) is unsafe, requiring HCP clarification (A). Splitting units (C) is unnecessary, and 4 hours (D) ignores heart failure needs.
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When assessing the client who is recovering from a radical hysterectomy with vulvectomy, the nurse notes lymphedema of the lower extremities. Which intervention should be implemented by the nurse?
- A. Elevate the head of the client’s bed to 45 degrees.
- B. Increase the client’s intake of fluids high in sodium.
- C. Encourage the client to exercise the lower extremities.
- D. Apply splints to both of the client’s lower extremities.
Correct Answer: C
Rationale: A. Elevating the head of the bed to a 45-degree angle may increase lymphedema of the lower extremities. B. Intake of fluids high in sodium will cause fluid retention. C. Leg exercises will improve drainage when lymphedema is present. D. Lower-extremity splints can cause skin breakdown of edematous tissue.
The nurse is caring for the client who had a left modified radical mastectomy (a total mastectomy with axillary node dissection and removal of the lining over the pectoralis major muscle). Which action by the nurse is appropriate?
- A. Have the client elevate the left arm above the head
- B. Ensure that IV access sites are only on the right side
- C. Have the client view the incision site as soon as possible
- D. Initiate left arm strengthening within 24 hours of surgery
Correct Answer: B
Rationale: A. The arm on the operative side should be elevated on a pillow, but not above the head. B. All IV access sites should be located on the nonoperative side to prevent circulatory impairment. C. Having the client look at the incision should be at the client’s readiness, not as soon as possible. D. Only ROM to the lower arm should be carried out for the first few days after surgery, with exercises and ROM to the shoulder after the drains are removed.
The nurse writes a diagnosis of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Encourage isometric exercises.
- B. Assist the client with activities of daily living (ADLs).
- C. Provide a high-protein diet.
- D. Refer to the physical therapist.
Correct Answer: B
Rationale: Assisting with ADLs (B) conserves energy in anemia-related activity intolerance. Isometric exercises (A) strain oxygen capacity, diet (C) is medical, and PT (D) is collaborative.
Ferrous sulfate is prescribed for a client. She returns to the clinic in two weeks. Which assessment by the nurse indicates that she has NOT been taking iron as ordered?
- A. The client's cheeks are flushed.
- B. The client reports having more energy.
- C. The client complains of nausea.
- D. The client's stools are light brown.
Correct Answer: D
Rationale: Iron turns stool black. Light brown stools indicate the client has not been taking iron as prescribed. Flushed cheeks, increased energy, and nausea can be associated with iron therapy compliance.
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis?
- A. Fever and infections.
- B. Nausea and vomiting.
- C. Excessive energy and high platelet counts.
- D. Cervical lymph node enlargement and positive acid-fast bacillus.
Correct Answer: A
Rationale: AML causes neutropenia, leading to fever/infections (A). Nausea (B) is nonspecific, high platelets/energy (C) are incorrect (AML causes thrombocytopenia/fatigue), and acid-fast bacillus (D) indicates TB, not AML.