The nurse is monitoring the transfusion of prescribed packed...

The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis

Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation

Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted

Pulmonary
Vital signs are RR 18, SpO 94% on room air

Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities

Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus

Genitourinary
Client is voiding amber-colored urine

The nurse is monitoring the transfusion of prescribed packed RBCs (PRBCs) initiated by the registered nurse. Which of the following actions are appropriate? Select all that apply.

A. The blood transfusion rate is set to infuse over 6 hours
B. The blood transfusion tubing is primed with lactated Ringer solution
C. The nurse stays with the client for the first 15 minutes of the transfusion
D. The PRBCs are administered through Y-type tubing with an in-line filter
E. The registered nurse verifies client and blood product identifiers with the licensed practical nurse

Correct Answer: C,D

Rationale: C) Appropriate: Staying for the first 15 minutes monitors for transfusion reactions. D) Appropriate: Y-type tubing with an in-line filter is standard for PRBCs to prevent complications. A) Inappropriate: PRBCs typically infuse over 2-4 hours, not 6, to avoid fluid overload. B) Inappropriate: Tubing is primed with normal saline, not lactated Ringer's, to prevent hemolysis. E) Inappropriate: Verification requires two registered nurses, not an LPN.

The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92

For each potential prescription, click to specify whether the prescription is anticipated or not anticipated at this time.

A. Administer propranolol
B. Administer methimazole
C. Perform a pregnancy test
D. Maintain a high-calorie diet
E. Offer moisturizing eye drops
F. Maintain continuous cardiac monitoring
G. Administer thyroid hormone replacement

Correct Answer: A,B,C,D,E,F

Rationale: A: Propranolol is anticipated to manage tachycardia and palpitations. B: Methimazole is anticipated to treat hyperthyroidism by reducing thyroid hormone production. C: A pregnancy test is anticipated due to the absence of menstruation for 3 months, as pregnancy can affect treatment choices. D: A high-calorie diet is anticipated to address weight loss and increased metabolism. E: Moisturizing eye drops are anticipated for exophthalmos-related eye dryness. F: Continuous cardiac monitoring is anticipated due to the high pulse rate (164). G: Thyroid hormone replacement is not anticipated, as the client has hyperthyroidism, not hypothyroidism.

The practical nurse is assisting the registered nurse with the care of a 58-year-old client in the emergency department.
Nurses' Notes
Initial Clinic Visit
The client monitors blood pressure (BP) at home and reports that it has been elevated for the past month. BP is 157/92 mm Hg. Physical examination is normal. The client is prescribed a thiazide diuretic for hypertension.

Emergency Department 4 Weeks Later
The client reports muscle weakness and severe cramping in the lower extremities with increased lethargy over the past 3 days. BP is 123/75 mm Hg. Physical examination findings include 1+ deep tendon reflexes bilaterally.

The nurse recognizes that the client is most likely experiencing.......... and, without prompt intervention, is at risk for...........

A. Hypokalemia
B. Hypoglycemia
C. Hypermagnesemia
D. Seizures
E. Hypotension
F. Cardiac dysrhythmias

Correct Answer: A,F

Rationale: The client is most likely experiencing hypokalemia and, without prompt intervention, is at risk for cardiac dysrhythmias. Thiazide diuretics can cause potassium loss, leading to muscle weakness, cramping, and lethargy. Low potassium levels can disrupt cardiac electrical activity, risking dysrhythmias.

The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air

Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air

The nurse should contact the health care provider and anticipate prescriptions for.....and.....

A. Naloxone
B. Thiamine
C. Haloperidol
D. Lorazepam

Correct Answer: B,D

Rationale: B: Thiamine is given to prevent Wernicke encephalopathy in alcohol withdrawal. D: Lorazepam manages withdrawal symptoms and prevents seizures. Naloxone is for opioid overdose, and haloperidol is not first-line for withdrawal.

The nurse recognizes that the client is most at risk for ___ related to ___

A. Seizures
B. Septic shock
C. Hypovolemic shock
D. Cellulitis
E. Substance withdrawal
F. Gastrointestinal bleeding

Correct Answer: A,E

Rationale: Seizures are a significant risk in alcohol withdrawal syndrome, which is suggested by the client's symptoms of trembling, diaphoresis, restlessness, and hallucinations.

Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.

The client has undergone surgical repair of tracheoesophageal fistula with esophageal atresia. The practical nurse is assisting the registered nurse to prepare the family for discharge home. Which of the following parent statements indicate that the teaching has been effective? Select all that apply.

A. I can expect my newborn to have a barking cough while the surgical site is healing.
B. I should ensure my newborn is in a semi-upright position during feedings.
C. I will call the clinic if I notice an increase in drooling or regurgitation with eating.
D. I will thin the texture of my newborn's formula by diluting it in sterile water.
E. The gastrostomy tube may need to stay in place after we leave the hospital.

Correct Answer: B,C,E

Rationale: A semi-upright position during feedings reduces reflux, reporting drooling or regurgitation ensures monitoring for complications, and acknowledging the gastrostomy tube's potential continued use shows understanding. A barking cough is not expected, and diluting formula is unsafe.