Nokea
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
- A. Slow the transfusion
- B. Document the finding as the only action
- C. Stop the blood transfusion and turn on the normal saline
- D. Assess the client's pupils
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.
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A student nurse is assigned to care for a client in a protective environment room. The nurse knows to intervene upon observing which of the following deliveries by the nursing student?
- A. indwelling catheterization kit
- B. flower bouquet
- C. tray of food containing disposable plate and utensils
- D. oral medication
Correct Answer: B
Rationale: Flowers can introduce allergens or pathogens, which are contraindicated in a protective environment. Other items are safe if sterile or disposable.
A nurse must teach a client how to do wound care and dressing changes prior to discharge. Which of the following are barriers to learning? Select all that apply.
- A. The client is 55 years old.
- B. The client is fearful.
- C. The client is illiterate.
- D. The client is weak and frail.
- E. The client has many questions about the procedures.
- F. The client is hard of hearing.
Correct Answer: B,C,F
Rationale: Barriers to learning include fear (B), which can hinder concentration; illiteracy (C), which affects understanding written instructions; and hearing impairment (F), which impedes verbal communication. Age 55 (A), weakness (D), and asking questions (E) are not barriers.
The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
- A. Hip
- B. Ankle
- C. Earlobe
- D. Chin
Correct Answer: C
Rationale: The earlobe is a suitable site for pulse oximetry in peripheral vascular disease, as it is less affected by impaired peripheral circulation.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
- A. The child is placed in a private room.
- B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- D. The staff uses standard precautions.
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients
An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
- A. Complete blood count
- B. Clean-catch urinalysis
- C. Liver profile
- D. Thyroid function test
Correct Answer: C
Rationale: A liver profile is required before starting isotretinoin due to its potential hepatotoxicity, ensuring safe administration.