Nokea
The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?
- A. Check the client's vital signs before starting the transfusion.
- B. Verify the client's identity and blood compatibility.
- C. Administer the blood with normal saline.
- D. Monitor the client for the first 15 minutes of the transfusion.
Correct Answer: B
Rationale: The correct answer is B: Verify the client's identity and blood compatibility. This step is crucial to prevent transfusion reactions due to compatibility issues. By confirming the client's identity and ensuring that the blood type matches, the healthcare provider minimizes the risk of adverse reactions such as hemolytic transfusion reactions. Checking vital signs (A) is important but ensuring blood compatibility takes precedence. Administering blood with normal saline (C) is incorrect as blood should be infused with the appropriate blood administration set. Monitoring the client for the first 15 minutes (D) is essential but verification of identity and blood compatibility is the primary step to prioritize safety.
You may also like to solve these questions
A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which pre-dialysis assessment finding should the nurse report to the healthcare provider?
- A. Serum potassium of 5.5 mEq/L.
- B. Blood pressure of 180/90 mm Hg.
- C. Heart rate of 80 beats per minute.
- D. Serum sodium of 140 mEq/L.
Correct Answer: B
Rationale: The correct answer is B: Blood pressure of 180/90 mm Hg. High blood pressure can worsen kidney function and increase the risk of cardiovascular complications during hemodialysis. The nurse should report this finding to the healthcare provider for prompt management.
A: Serum potassium of 5.5 mEq/L is slightly elevated but not an immediate concern before hemodialysis.
C: Heart rate of 80 beats per minute is within normal range and not a priority assessment for pre-dialysis.
D: Serum sodium of 140 mEq/L is within normal limits and does not require immediate attention before hemodialysis.
A 40-year-old woman presents with a history of chronic constipation, bloating, and abdominal pain. She notes that the pain is relieved with defecation. She denies any weight loss, blood in her stools, or nocturnal symptoms. Physical examination and routine blood tests are normal. What is the most likely diagnosis?
- A. Inflammatory bowel disease
- B. Irritable bowel syndrome
- C. Celiac disease
- D. Lactose intolerance
Correct Answer: B
Rationale: The correct answer is B: Irritable bowel syndrome (IBS). The key clues in the question are chronic constipation, bloating, abdominal pain relieved with defecation, and absence of alarming symptoms. These symptoms align with the Rome IV criteria for IBS. Inflammatory bowel disease (A) typically presents with more severe symptoms, including weight loss and blood in stools. Celiac disease (C) is associated with malabsorption symptoms and autoimmune features, not typically seen in this case. Lactose intolerance (D) presents with symptoms after consuming dairy, which is not mentioned in the patient's history. Therefore, based on the clinical presentation and exclusion of other conditions, the most likely diagnosis is IBS.
A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which instruction should the nurse provide?
- A. Avoid green leafy vegetables.
- B. Take aspirin for headaches.
- C. Use a soft-bristled toothbrush.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: The correct answer is C: Use a soft-bristled toothbrush. Patients on warfarin are at risk for bleeding due to its anticoagulant effect. Using a soft-bristled toothbrush helps prevent gum bleeding and injury to the gums, reducing the risk of bleeding complications. Avoiding green leafy vegetables (choice A) is not necessary, as consistent intake is key for warfarin dosing. Taking aspirin (choice B) can increase the risk of bleeding. Limiting fluid intake (choice D) is not indicated in this case.
When assessing a client with a chest tube connected to suction, which observation indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation in the water seal chamber.
- D. Steady bubbling in the suction control chamber.
Correct Answer: D
Rationale: The correct answer is D: Steady bubbling in the suction control chamber. This indicates proper functioning as it shows that the suction is maintaining a consistent pressure, which is essential for effective drainage and lung re-expansion. Continuous bubbling in the water seal chamber (choice A) indicates an air leak. Intermittent bubbling in the suction control chamber (choice B) could suggest fluctuating pressure. No fluctuation in the water seal chamber (choice C) indicates either a blockage or disconnection. Steady bubbling in the suction control chamber (choice D) indicates the suction is working consistently, ensuring proper drainage and lung re-expansion.
A 46-year-old man with a history of cirrhosis is brought in by his wife because he has been acting strangely. On examination, he is disoriented, ataxic, and has slurred speech. He is also hyperreflexic. His white blood cell count is normal. His hematocrit is 34%. Coagulation times are elevated. His ammonia level is normal. Which of the following statements regarding his management is correct?
- A. He should be treated with a low-protein diet and lactulose
- B. Lorazepam is not the drug of choice to control his behavior
- C. He should not be placed on gentamicin prophylactically to prevent the development of peritonitis
- D. If the patient complains of pain, acetaminophen should be avoided and nonsteroidal anti-inflammatory agents should be used
Correct Answer: A
Rationale: The correct answer is A: He should be treated with a low-protein diet and lactulose. This patient is presenting with hepatic encephalopathy, as evidenced by his altered mental status, ataxia, slurred speech, hyperreflexia, and normal ammonia level. The management of hepatic encephalopathy involves reducing the production of ammonia in the gut. Lactulose is a non-absorbable disaccharide that helps trap ammonia in the gut and promote its excretion in the feces. A low-protein diet is also recommended to decrease ammonia production.
Option B is incorrect because lorazepam is not the drug of choice for managing hepatic encephalopathy; it can worsen the condition. Option C is incorrect because gentamicin is not indicated in this scenario. Option D is incorrect because acetaminophen should be avoided in patients with liver disease due to the risk of hepatotoxicity; nonsteroidal anti-inflammatory drugs