Nokea
The nurse is caring for a client receiving a unit of packed red blood cells (PRBCs). The client reports chills, and their oral temperature is 103° F (39.4° C). Which action should the nurse take first?
- A. Assess the client's blood pressure and heart rate
- B. Obtain blood cultures
- C. Pause the transfusion
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: C
Rationale: Chills and a fever of 103°F during a PRBC transfusion suggest a possible febrile or hemolytic reaction. The first action is to pause the transfusion to prevent further administration of potentially problematic blood. Assessing vital signs, obtaining cultures, and notifying the provider follow after stopping the transfusion.
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A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
- A. It must have been eating too many foods with salt in them. Salt pulls water with it.'
- B. The swelling in his ankles must have moved up closer to his heart so the fluid circulates better.'
- C. He must have forgotten to take his daily water pill.'
- D. Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels.'
Correct Answer: D
Rationale: Cirrhosis causes portal hypertension and hypoalbuminemia, leading to ascites (D). Salt intake (A) may worsen but isn't the primary cause. Ankle edema (B) and diuretics (C) are secondary factors.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
- A. Keeping the client flat on one side or the other.
- B. Elevating the head of the bed to 30 degrees.
- C. Logrolling or turning as a unit when turning.
- D. Keeping the neck in a neutral position.
Correct Answer: A
Rationale: Keeping the client flat is contraindicated after a posterior fossa craniotomy, as it increases ICP. Elevating the head, logrolling, and neutral neck positioning promote venous drainage and spinal alignment, reducing ICP risk.
The nurse should ask all clients age 65 or older who are having surgery which question?
- A. Do you have Medicare Part A to help pay for the hospital reimbursement?'
- B. œDo you have an advance directive such as a health care proxy or living will?'
- C. œDo you have extra coverage to help pay for medications?'
- D. œDo you have Medicare Part B to help pay for your expenses?'
Correct Answer: B
Rationale: Asking about an advance directive ensures the client's wishes are documented, especially critical for older adults facing surgical risks, to guide care in case of incapacity.