Nokea
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
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A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the correct choice because it does not have an antiplatelet effect like aspirin, ibuprofen, and naproxen sodium. Enoxaparin is an anticoagulant that works by preventing blood clots, so it is safer to take acetaminophen for pain relief as it does not increase the risk of bleeding. Aspirin, ibuprofen, and naproxen sodium can increase the risk of bleeding when taken with enoxaparin due to their antiplatelet effects. Therefore, acetaminophen is the safest option for pain relief while on enoxaparin therapy.
A nurse is planning teaching for a client who is trying to quit smoking. Which of the following instructions about nicotine replacement options should the nurse include?
- A. Change the nicotine patch every other day.
- B. Do not drink beverages while sucking on a nicotine lozenge.
- C. Chew nicotine gum for 10 min before spitting it out.
- D. Administer 2 sprays of nicotine nasal spray in each nostril with each dose.
Correct Answer: B
Rationale: The correct answer is B: Do not drink beverages while sucking on a nicotine lozenge. This instruction is important because beverages can interfere with the absorption of nicotine from the lozenge. Nicotine replacement therapy works best when the nicotine is absorbed properly, so avoiding beverages while using the lozenge will help ensure its effectiveness. Changing the nicotine patch every other day (choice A) is incorrect as patches are typically changed daily. Chewing nicotine gum for 10 minutes before spitting it out (choice C) is incorrect as the gum should be chewed until a tingling sensation is felt, then parked between the cheek and gum. Administering 2 sprays of nicotine nasal spray in each nostril with each dose (choice D) is incorrect as the dosage is usually one spray in each nostril.
A nurse is reviewing the medical record of a client who has sinusitis and a new prescription for cefuroxime. Which of the following client information is the priority for the nurse to report to the provider?
- A. The client has a BUN of 18 mg/dL
- B. The client takes an aspirin daily
- C. The client has a history of a severe penicillin allergy
- D. The client reports a history of nausea with cefuroxime
Correct Answer: C
Rationale: The correct answer is C: The client has a history of a severe penicillin allergy. This is the priority for the nurse to report because cefuroxime belongs to the cephalosporin class of antibiotics, which has a cross-reactivity with penicillins. Individuals with a history of severe penicillin allergy are at an increased risk of also being allergic to cephalosporins like cefuroxime. This can lead to potentially life-threatening allergic reactions. Reporting this information to the provider is crucial to avoid prescribing a medication that could harm the client.
Choice A (BUN of 18 mg/dL) is not directly related to the prescription of cefuroxime for sinusitis. Choice B (client takes an aspirin daily) is important but not as critical as the potential allergic reaction to cefuroxime. Choice D (client reports a history of nausea with cefuroxime) is relevant but does not pose an
A nurse is caring for a client who has a respiratory infection and is receiving an antibiotic. Which of the following medications puts the client at risk for developing hearing loss?
- A. Rifampin
- B. Ciprofloxacin
- C. Penicillin G
- D. Gentamicin
Correct Answer: D
Rationale: The correct answer is D: Gentamicin. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, leading to hearing loss. The medication affects the inner ear's hair cells, resulting in irreversible damage. Rifampin (A), Ciprofloxacin (B), and Penicillin G (C) are not associated with ototoxicity. In summary, Gentamicin (D) is the only medication in the choices that poses a risk for hearing loss due to its ototoxic effects on the inner ear.
A nurse is reviewing the laboratory values of a client who is taking atorvastatin. Which of the following laboratory values indicates the treatment has been effective?
- A. BUN 15 mg/dL
- B. Blood glucose 90 mg/dL
- C. Urine specific gravity 1.020
- D. LDL 120 mg/dL
Correct Answer: D
Rationale: The correct answer is D: LDL 120 mg/dL. Atorvastatin is a medication used to lower LDL cholesterol levels. A decrease in LDL levels indicates the effectiveness of the treatment in reducing the risk of cardiovascular events. BUN, blood glucose, and urine specific gravity are not directly related to the effectiveness of atorvastatin in lowering cholesterol levels. BUN reflects kidney function, blood glucose monitors glucose levels, and urine specific gravity indicates hydration status. Therefore, D is the best indicator of treatment effectiveness.