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The nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. What action should the nurse take?
- A. Return the bag to the blood bank.
- B. Infuse the blood using filter tubing.
- C. Add 10 mL normal saline to the bag.
- D. Agitate the bag to mix contents gently.
Correct Answer: A
Rationale: The nurse should return the unit of blood to the blood bank because the gas bubbles in the bag indicate possible contamination. Whenever administering blood, the nurse would use filter tubing to trap particulate matter. Although normal saline can be infused concurrently with the blood, normal saline or any other substance should never be added to the blood in a blood bag. The bag should not be agitated because this can harm red blood cells.
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During a routine prenatal visit, a client in her third trimester of pregnancy reports having frequent calf pain when she walks. The nurse suspects superficial thrombophlebitis and checks for which sign associated with this condition?
- A. Severe chills
- B. Kernig's sign
- C. Brudzinski's sign
- D. Palpable hard thrombus
Correct Answer: D
Rationale: Pain in the calf during walking could indicate venous thrombosis or peripheral arterial disease. The manifestations of superficial thrombophlebitis include a palpable thrombus that feels bumpy and hard, tenderness and pain in the affected lower extremity, and a warm and pinkish red color over the thrombus area. Severe chills can occur in a variety of inflammatory or infectious conditions and are also a manifestation of pelvic thrombophlebitis. Brudzinski's sign and Kernig's sign test for meningeal irritability.
A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. Which should the nurse assess the client for before the procedure to best assure the client's safety?
- A. Allergies
- B. Familial renal disease
- C. Frequent antibiotic use
- D. Long-term diuretic therapy
Correct Answer: A
Rationale: The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used.
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
The nurse is teaching the parents of a child diagnosed with celiac disease about dietary measures. The nurse should instruct the parents to take which measure?
- A. Restrict corn and rice in the diet.
- B. Restrict fresh vegetables in the diet.
- C. Substitute grain cereals with pasta products.
- D. Avoid foods that are hidden sources of gluten.
Correct Answer: D
Rationale: Gluten is found primarily in the grains of wheat, rye, barley, and oats. Gluten is added to many foods as hydrolyzed vegetable protein that is derived from cereal grains; therefore, labels need to be read. Corn and rice, as well as vegetables, are acceptable in a gluten-free diet, and corn and rice become substitute foods. Many pasta products contain gluten.
The pediatric nurse specialist teaches nursing students about mumps. Which clinical manifestation will the specialist identify as the most common complication of this disease?
- A. Pain
- B. Nuchal rigidity
- C. Impaired hearing
- D. A red swollen testicle
Correct Answer: B
Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication.