Nokea
The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?
- A. Low-pressure alarm
- B. Increased blood glucose
- C. Diminished lung sounds
- D. Hemoglobinuria
Correct Answer: D
Rationale: Hemoglobinuria (blood in the urine) is a hallmark of a hemolytic transfusion reaction, indicating red blood cell destruction. Low-pressure alarms relate to ventilator issues, increased glucose is unrelated, and diminished lung sounds may suggest other issues but not specifically transfusion reactions.
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The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations:
- A. Returning to work after a weekend.
- B. Going on vacation.
- C. Having oral surgery.
- D. Having a routine medical checkup.
Correct Answer: C
Rationale: Oral surgery is a stressful event requiring increased glucocorticoid supplementation to prevent adrenal crisis.
A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
Cimetidine (Tagamet) may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following?
- A. Esophageal reflux.
- B. Dysphagia.
- C. Esophagitis.
- D. Ulcer formation.
Correct Answer: C
Rationale: Cimetidine, an H2-receptor antagonist, reduces gastric acid production, helping to prevent esophagitis caused by acid reflux in hiatal hernia.
The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
- A. The need to remove as much of the leg as possible.
- B. The adequacy of the blood supply to the tissues.
- C. The ease with which a prosthesis can be fitted.
- D. The client's ability to walk with a prosthesis.
Correct Answer: B
Rationale: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
A client with angina has been taking nifedipine. The nurse should teach the client to:
- A. Monitor blood pressure monthly.
- B. Perform daily weights.
- C. Inspect gums daily.
- D. Limit intake of green leafy vegetables.
Correct Answer: C
Rationale: Nifedipine, a calcium channel blocker, can cause gingival hyperplasia. Daily gum inspection helps detect this side effect early.