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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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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. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.
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.
Which information is most important for the nurse to reinforce with a male client who is about to undergo a vasectomy?
- A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.'
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.'
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you may return to work as soon as you feel up to it.'
- D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.'
Correct Answer: A
Rationale: All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control until the absence of sperm in the ejaculate is confirmed.
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.
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. exercise doing weight bearing activities
- B. exercise to reduce weight
- C. avoid exercise activities that increase the risk of fracture
- D. exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: exercise doing weight bearing activities. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.