Nokea
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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A client is brought to the emergency department reporting chest pain. Assessment shows vital signs that include a blood pressure (BP) of 150/90 mm Hg, pulse (P) 88 beats per minute (BPM), and respirations (R) 20 breaths per minute. The nurse administers nitroglycerin 0.4 mg sublingually. The treatment is found to be effective when the reassessment of vital signs shows which data?
- A. BP 150/90 mm Hg, P 70 BPM, R 24 breaths per minute
- B. BP 100/60 mm Hg, P 96 BPM, R 20 breaths per minute
- C. BP 100/60 mm Hg, P 70 BPM, R 24 breaths per minute
- D. BP 160/100 mm Hg, P 120 BPM, R 16 breaths per minute
Correct Answer: B
Rationale: Nitroglycerin dilates both arteries and veins, causing blood to pool in the periphery. This causes a reduced preload and therefore a drop in cardiac output. This vasodilation causes the blood pressure to fall. The drop in cardiac output causes the sympathetic nervous system to respond and attempt to maintain cardiac output by increasing the pulse. Beta blockers, such as propranolol, are often used in conjunction with nitroglycerin to prevent this rise in heart rate. If chest pain is reduced and cardiac workload is reduced, the client will be more comfortable; therefore, a rise in respirations should not be seen.
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.
A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.
The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?
- A. Serum insulin level
- B. Heel stick blood glucose
- C. Rh and ABO blood typing
- D. Indirect and direct bilirubin levels
Correct Answer: B
Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth.