Nokea
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
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Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
- A. I noticed a little lump a little above the belly button.
- B. The baby seems hungry all the time.
- C. Mild vomiting turned into vomiting that shot across the room.
- D. We notice irritation and spitting up immediately after feedings.
Correct Answer: C
Rationale: Mild vomiting turned into vomiting that shot across the room. Projectile vomiting is a hallmark of pyloric stenosis.
A client has a chest tube inserted for treatment of a hemothorax.
Which of the following findings would indicate to the nurse that there is a problem with the effective functioning of the chest tube?
- A. 15-cm of water is present in the suction control chamber.
- B. Constant bubbling is observed in the water seal chamber.
- C. 2-cm of water is present in the water seal chamber.
- D. Clots of blood are observed in the collection chamber.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) appropriate, regulates the amount of suction delivered to the patient (2) correct-would indicate an air leak, would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding
The nurse is caring for a client with a history of myasthenia gravis.
- A. Which instruction is most important for a client with myasthenia gravis?
- B. Take pyridostigmine on an empty stomach.
- C. Avoid crowds to prevent infections.
- D. Restrict physical activity completely.
- E. Monitor blood pressure daily.
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, critical in myasthenia gravis due to immunosuppressive therapy. Pyridostigmine is taken with food, activity is encouraged, and blood pressure monitoring is not primary.
A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is associated with this therapy?
- A. Check the skin on the sacrum for breakdown
- B. Inspect the pin site for signs of infection
- C. Auscultate the lungs for atelectasis
- D. Perform a neurovascular check for circulation
Correct Answer: D
Rationale: Perform a neurovascular check for circulation. While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell's traction is Buck's traction with a sling under the knee.
A client with severe bilateral peripheral edema.
Which of the following is the BEST way for the nurse to determine the degree of edema in a limb, and the client's response to treatment?
- A. Measure both limbs with the tape measure and compare.
- B. Depress the skin and rank the degree of pitting.
- C. Describe the swelling in the affected area.
- D. Pinch the skin and note how quickly it returns to normal.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not the best way to evaluate for peripheral edema (2) correct-severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration