Nokea
The nurse is caring for a client requiring an emergent transfusion of packed red blood cells. The nurse checks the blood bank, but the only available blood is O + (positive). The client's blood type is A+ (positive). What is the nurse's most appropriate action?
- A. Arrange for a cross-match between the available blood and the client's blood.
- B. Call the other blood banks and ask if they have blood units available with the client’s blood type.
- C. Notify the physician that there is no available blood in the blood bank.
- D. Call the client’s family and tell them that he needs blood.
Correct Answer: A
Rationale: In an emergency, O+ blood can be safely transfused to an A+ client, as O+ is the universal donor for red blood cells. Arranging for a cross-match ensures compatibility and is the most appropriate action. Contacting other blood banks or notifying the physician delays care, and calling the family is inappropriate.
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When administering I.V. midazolam hydrochloride (Versed) the nurse should?
- A. Assess the blood pressure.
- B. Monitor the pulse oximeter.
- C. Encourage slow, deep breaths.
- D. Explain relaxation techniques.
Correct Answer: B
Rationale: Midazolam can cause respiratory depression, so monitoring the pulse oximeter is essential to ensure adequate oxygenation during administration.
A client undergoing a bilateral adrenalectomy has postoperative orders for hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours as needed for pain. The medication is administered in relatively small doses primarily because it is:
- A. Less likely to cause dependency in small doses.
- B. Less irritating to subcutaneous tissues in small doses.
- C. As potent as most other analgesics in larger doses.
- D. Excreted before accumulating in toxic amounts in the body.
Correct Answer: C
Rationale: Hydromorphone is a potent opioid, effective in small doses, reducing the need for larger doses that increase side effect risks.
The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia?
- A. Nervousness.
- B. Anorexia.
- C. Kussmaul's respirations.
- D. Bradycardia.
Correct Answer: A
Rationale: Nervousness is a common symptom of hypoglycemia due to the body's stress response to low blood glucose levels.
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
Which of the following factors places a client at greatest risk for skin cancer?
- A. Fair skin and history of chronic sun exposure.
- B. Caucasian race and history of hypertension.
- C. Dark skin and family history of skin cancer.
- D. Dark skin and history of hypertension.
Correct Answer: A
Rationale: Fair skin and chronic sun exposure increase skin cancer risk due to higher UV sensitivity and cumulative damage. Dark skin offers some protection.