Nokea
The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?
- A. Slow the transfusion rate and administer diphenhydramine.
- B. Stop the transfusion and notify the physician.
- C. Increase the transfusion rate to complete it quickly.
- D. Administer acetaminophen for discomfort.
Correct Answer: B
Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority
You may also like to solve these questions
The nurse is caring for a client who fractured her leg in a motor vehicle accident. A cast is applied. The nurse will assess which of the following? Select all that apply.
- A. pulses
- B. capillary refill
- C. skin temperature
- D. squeeze the cast every hour to check for firmness
- E. assess for pain, numbness, tingling, or inability to move the toes
Correct Answer: A, B, C, E
Rationale: Assessing pulses, capillary refill, skin temperature, and neurovascular symptoms (pain, numbness, tingling, movement) ensures circulation and nerve function are intact; squeezing the cast is inappropriate.
Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.
- A. Checking temperature and vital signs for a client acutely ill with sepsis.
- B. Checking routine temperature and vital signs for clients at the beginning of the shift.
- C. Emptying catheter bags and measuring the urinary output from Foley catheters.
- D. Monitoring the transfusion of red blood cells.
- E. Assisting an ambulatory client to walk to the bathroom.
Correct Answer: B,C,E
Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (B), measuring urinary output (C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (A) and monitoring a transfusion (D) require a nurse's assessment skills.
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
- A. Hib titer
- B. Mumps vaccine
- C. Hepatitis B vaccine
- D. MMR
Correct Answer: C
Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
- A. Hallucinogenic drugs create both stimulant and depressant effects.
- B. Hallucinogenic drugs induce a state of altered perception.
- C. Hallucinogenic drugs produce severe respiratory depression.
- D. Hallucinogenic drugs induce rapid physical dependence.
Correct Answer: B
Rationale: Continuous observation is needed due to the altered perception caused by hallucinogens, which can lead to unsafe behaviors.
A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.