Nokea
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should:
- A. Begin chest compressions.
- B. Call the rapid response team.
- C. Remove the family from the room.
- D. Ventilate the client with an ambu bag.
Correct Answer: B
Rationale: Unresponsiveness, hypotension, and low SpO2 indicate a critical condition. Calling the rapid response team ensures immediate multidisciplinary intervention.
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A client with an ileal conduit reports a bulging stoma. The nurse suspects:
- A. Stoma retraction.
- B. Parastomal hernia.
- C. Stoma ischemia.
- D. Infection.
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to:
- A. Keep the hands and feet elevated as much as possible
- B. Use a vibrating massage device on the hands
- C. Wear gloves when obtaining food from the refrigerator
- D. Increase coffee intake to 2 cups per day
Correct Answer: C
Rationale: Wearing gloves when obtaining food from the refrigerator prevents cold-triggered vasospasm in Raynaud's. Elevation is irrelevant, vibrating devices may worsen symptoms, and coffee (caffeine) can cause vasoconstriction, increasing episodes.
When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
- A. Send freshly-collected urine samples to the laboratory.
- B. Return the remainder of the blood component unit to the blood bank.
- C. Return the intravenous administration set to the blood bank.
- D. Alert Risk Management about the incident.
- E. Report the incident to the Infection Control Manager.
Correct Answer: A,B
Rationale: After a transfusion reaction, the nurse should send urine samples to check for hemolysis and return the remaining blood unit to the blood bank for analysis. The IV administration set is not typically returned, and while Risk Management and Infection Control may be notified, these are not immediate actions.
A client has been admitted with active rectal bleeding. He has been typed and cross-matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints when getting up to go to the bedside commode. The nurse notifies the health care provider, who orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for immediate transfusion?
- A. A negative.
- B. B negative.
- C. AB negative.
- D. O negative.
Correct Answer: D
Rationale: In an emergency situation requiring immediate transfusion, such as when a client with active bleeding faints, O negative blood is used because it is the universal donor type. O negative blood can be safely transfused to any patient regardless of their blood type, minimizing the risk of a transfusion reaction when there is no time for type and cross-match verification.
When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply.
- A. Epigastric pain at night.
- B. Relief of epigastric pain after eating.
- C. Vomiting.
- D. Weight loss.
- E. Melena.
Correct Answer: A,C,E
Rationale: Gastric ulcers commonly cause epigastric pain at night, vomiting, and melena (dark, tarry stools) due to bleeding. Relief of pain after eating is more typical of duodenal ulcers, and weight loss is less common with gastric ulcers.