Nokea
The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.
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When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. Relaxation and sleep
- B. Deep breathing and coughing
- C. Incisional healing
- D. Range of motion exercises
Correct Answer: B
Rationale: Effective pain management encourages deep breathing and coughing, which are crucial for preventing complications after thoracic surgery. These actions help prevent respiratory complications such as pneumonia and atelectasis, promote lung expansion, and improve oxygenation. While relaxation and sleep are important for recovery, the priority after a thoracotomy and lobectomy is to prevent respiratory issues. Incisional healing is important but not the primary focus immediately post-surgery. Range of motion exercises are not directly related to promoting recovery after thoracic surgery.
A client wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?
- A. Blueberries
- B. Soybean oil
- C. Citrus fruits
- D. Green tea
Correct Answer: B
Rationale: The correct answer is B: Soybean oil. Soybean oil is a good source of omega-3 fatty acids, which are beneficial for heart health. Blueberries (choice A), citrus fruits (choice C), and green tea (choice D) are not significant sources of omega-3 fatty acids. Blueberries are rich in antioxidants, citrus fruits provide vitamin C, and green tea contains polyphenols, but they do not offer a substantial amount of omega-3 fatty acids compared to soybean oil.
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
- A. diaphoresis with decreased urinary output
- B. increased heart rate with increased respirations
- C. improved respiratory status and increased urinary output
- D. decreased chest pain and decreased blood pressure
Correct Answer: C
Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.
Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?
- A. Assessing the client's level of consciousness
- B. Monitoring the client's oxygen saturation
- C. Checking the client's gag reflex before eating or drinking
- D. Monitoring the client's intake and output
Correct Answer: C
Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.