Nokea
The nurse is assessing a client who is receiving a transfusion of platelets. The client's blood type is A-negative, and the client is receiving O-positive platelets. Which of the following actions should the nurse take?
- A. Assess the client for fluid volume deficit
- B. Document the assessment findings
- C. Stop the transfusion
- D. Notify the primary health care provider
Correct Answer: C
Rationale: Platelets from O-positive donors can cause an Rh incompatibility reaction in an A-negative client, as Rh-positive platelets may sensitize the client. The nurse should stop the transfusion and notify the provider. Fluid volume deficit is unrelated, and documenting without stopping the transfusion is inadequate.
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Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
- A. Anorexia.
- B. Tachycardia.
- C. Weight gain.
- D. Cold skin.
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
- A. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.
- B. Nitroglycerin should be avoided if the client is experiencing this serious side effect.
- C. Taking the nitroglycerin with a few glasses of water will reduce the problem.
- D. The client should lie in a supine position to alleviate the headache.
Correct Answer: A
Rationale: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.
A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to:
- A. Increase the frequency of self-monitoring (blood glucose testing).
- B. Reduce food intake to diminish nausea.
- C. Discontinue insulin if unable to eat.
- D. Take half of the normal dose of insulin.
Correct Answer: A
Rationale: Influenza can increase blood glucose levels due to stress and illness, requiring more frequent monitoring to adjust insulin doses.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 1 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which of the following assessment findings from the triage note require immediate follow-up? Select all that apply.
- A. blood pressure
- B. temperature
- C. pulse and respirations
- D. pulse oximetry
- E. lung sounds
- F. neurological assessment findings
- G. thready peripheral pulses
Correct Answer: A,B,C,F,G
Rationale: Blood pressure (94/57) indicates hypotension, temperature (105°F) suggests hyperthermia, pulse (115) and respirations (26) indicate tachycardia and tachypnea, neurological findings (lethargy, confusion) suggest altered mental status, and thready pulses indicate poor perfusion—all requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.