Nokea
The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?
- A. Check the client's vital signs before starting the transfusion.
- B. Use a blood filter when administering the transfusion.
- C. Verify the blood type and Rh factor with another healthcare professional.
- D. Administer antihistamines before starting the transfusion.
Correct Answer: C
Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.
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An older client requiring total care resides with a family consisting of two daughters who take shifts providing care around-the-clock. During a home visit, the daughters ask the nurse about resources that are available for client care while they attend a scheduled family reunion. Which information is best for the nurse to provide?
- A. propose the family seek assistance for care in the area of the reunion's location
- B. tell the caregivers to consider hiring a private duty nurse during the time away
- C. advise to have a case management evaluation of the client's home environment
- D. suggest social services be contacted to find a respite care facility for the client
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?
- A. Instruct the client to monitor her blood pressure at home
- B. Refer the client to her healthcare provider for further evaluation
- C. Educate the client on lifestyle changes to reduce blood pressure
- D. Recheck the blood pressure in 15 minutes
Correct Answer: B
Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.
The healthcare provider is assessing a client with a suspected myocardial infarction. Which finding requires immediate intervention?
- A. Chest pain radiating to the left arm.
- B. Shortness of breath.
- C. Nausea and vomiting.
- D. Diaphoresis.
Correct Answer: B
Rationale: Shortness of breath is a critical sign that can indicate heart failure or pulmonary edema, conditions that require immediate intervention in a client with a suspected myocardial infarction. Chest pain radiating to the left arm is a classic symptom of a myocardial infarction but may not necessitate immediate intervention compared to severe shortness of breath. Nausea and vomiting can be present in myocardial infarction but are not as urgent as shortness of breath. Diaphoresis, or sweating, is a common symptom of a myocardial infarction but may not be as immediately concerning as significant shortness of breath.
The nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates a need for further teaching?
- A. I will use my albuterol inhaler before exercising.
- B. I will avoid secondhand smoke.
- C. I will get a flu shot every year.
- D. I will limit my fluid intake to 2 liters per day.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of hypertension is admitted with a blood pressure of 180/110 mm Hg. Which medication should the nurse prepare to administer?
- A. Atenolol (Tenormin)
- B. Nifedipine (Procardia)
- C. Hydrochlorothiazide (Microzide)
- D. Clonidine (Catapres)
Correct Answer: D
Rationale: In this scenario of severe hypertension (180/110 mm Hg), the nurse should prepare to administer Clonidine (Catapres), which is an antihypertensive medication commonly used to rapidly lower blood pressure in acute situations. Atenolol and Nifedipine are also antihypertensive medications, but Clonidine is more appropriate for immediate blood pressure reduction in this critical situation. Hydrochlorothiazide is a diuretic often used for long-term management of hypertension, not for rapid lowering of severely elevated blood pressure.