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The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?
- A. Administer prescribed diphenhydramine (Benadryl).
- B. Continue to monitor the client's vital signs.
- C. Stop the infusion of packed red blood cells.
- D. Slow the infusion rate of the transfusion
Correct Answer: D
Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.
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A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?
- A. Pupil response
- B. Motor function
- C. Respiratory status
- D. Short-term memory
Correct Answer: C
Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.
A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?
- A. Airborne
- B. Standard
- C. Contact
- D. Droplet
Correct Answer: A
Rationale: The correct answer is 'Airborne.' Varicella (chickenpox) is caused by the varicella-zoster virus, which spreads through the air by respiratory droplets. Therefore, placing the client on airborne precautions is necessary to prevent the transmission of the virus. Choice B, 'Standard precautions,' involve basic infection prevention measures that are used for all client care. Choice C, 'Contact precautions,' are used for diseases that spread by direct or indirect contact. Choice D, 'Droplet precautions,' are implemented for diseases transmitted by respiratory droplets that are larger than 5 microns.
The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which
interventions are used to help prevent infection in this client? (Select one that doesn't apply.)
- A. Use sterile gloves and gowns whenever the nursing staff is in contact with the client.
- B. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her
use only - C. Request that the family take home the fresh flowers that are at the client's bedside
- D. Assist the client with meticulous oral care after meals and at bedtime.
Correct Answer: A
Rationale:
What intervention is most important to teach the client about identifying the onset of dehydration?
- A. Measuring abdominal girth
- B. Converting ounces to milliliters
- C. Obtaining and charting daily weight
- D. Selecting food items with high water content
Correct Answer: C
Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.
The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?
- A. Document the observation in the chart.
- B. Measure urine specific gravity and volume.
- C. Assess the pulse and blood pressure.
- D. Assess the client's deep tendon reflexes.
Correct Answer: C
Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.