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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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.
A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. The nurse should explain that which of the following food sources contains iron that is most easily absorbed by the body?
- A. Spinach
- B. Dried apricots
- C. Chicken
- D. Lentils
Correct Answer: C
Rationale: The correct answer is C, 'Chicken.' Heme iron from animal sources, such as chicken, is more easily absorbed by the body compared to non-heme iron from plant sources like spinach, dried apricots, and lentils. While plant-based iron sources are beneficial, they are not as readily absorbed by the body as heme iron from animal products.
A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keeping conversations short is the most appropriate intervention to promote comfort for a client with pneumonia. Pneumonia can be physically exhausting, and limiting the length of conversations helps conserve the client's energy. Encouraging visits from family and friends (Choice B) may be emotionally supportive but might not directly promote comfort in the context of conserving energy during recovery. Increasing oral fluid intake (Choice A) is important for hydration but may not directly address the client's comfort. Monitoring vital signs frequently (Choice D) is essential for assessing the client's condition but does not directly promote comfort.
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
- C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
Correct Answer: C
Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.
Which information is a priority for the client to reinforce after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours as the preparation and test are tiring.
- C. During waking hours, drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure urine output for the next day and immediately notify the healthcare provider if it decreases.
Correct Answer: D
Rationale: After intravenous pyelography, monitoring urine output is crucial to assess kidney function and detect any early signs of complications. Decreased urine output could indicate a problem with kidney function or potential complications from the procedure. While rest and hydration are important, the priority lies in monitoring urine output for any abnormalities. Eating a light diet may be recommended, but it is not the priority post-procedure instruction.