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The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half 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: Stop the infusion. This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.
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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: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances.
After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
- A. 3 oz broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
- A. Esophagitis
- B. Leukopenia
- C. Fatigue
- D. Skin irritation
Correct Answer: B
Rationale: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.'
- B. The tube will remove excess air from your chest.'
- C. The tube controls the amount of air that enters your chest.'
- D. The tube will seal the hole in your lung.'
Correct Answer: B
Rationale: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
The charge nurse is assigning staff to care for the client with disseminated herpes zoster. Which staff member should the charge nurse exclude from being assigned?
- A. A 7-month pregnant nurse who had confirmed chicken pox in childhood
- B. A 32-year-old nurse with unknown disease or vaccination history for chicken pox
- C. A 28-year-old nurse with a history of varicella vaccine and 2 small children at home
- D. A 60-year-old nurse with a history of live herpes zoster vaccine
Correct Answer: B
Rationale: B: Unknown immunity status poses a risk of varicella infection. A, C, D: These staff have immunity via prior infection or vaccination.