Nokea
The nurse is preparing to administer a blood transfusion. Which solution should be used to prime the tubing?
- A. Dextrose 5% in water.
- B. Lactated Ringer's.
- C. 0.9% sodium chloride.
- D. Heparinized saline.
Correct Answer: C
Rationale: 0.9% sodium chloride is compatible with blood products and used to prime tubing to prevent hemolysis.
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A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.
A client with pancreatitis is admitted with severe abdominal pain. Which position should the nurse encourage to reduce discomfort?
- A. Supine with legs elevated
- B. Side-lying with knees flexed
- C. Prone with a pillow under the abdomen
- D. Sitting upright
Correct Answer: B
Rationale: Side-lying with knees flexed reduces tension on the abdominal muscles and pancreas, helping to alleviate pain in pancreatitis.
After your assessment of your client and the need to transfer your client from the bed to the chair, what is the best and safest way to transfer this paralyzed client when you suspect that you will need the help of another for the client's first transfer out of bed?
- A. Use a slide board.
- B. Use a mechanical lift.
- C. Use a gait belt.
- D. Notify the client's doctor that the client cannot be safely transferred by you.
Correct Answer: B
Rationale: For a paralyzed client requiring assistance, a mechanical lift is the safest transfer method, minimizing risk of injury to both the client and staff.
A client who is paraplegic cannot feel her lower extremities and has been positioned on her side. The nurse should inspect which of the following areas that is a potential pressure point when the client is in this position?
- A. Sacrum.
- B. Occiput.
- C. Ankles.
- D. Heel.
Correct Answer: C
Rationale: When side-lying, the ankles are a common pressure point due to prolonged contact with the bed. The sacrum, occiput, and heel are more at risk in other positions like supine.
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
- A. Normal sinus rhythm.
- B. Sinus tachycardia.
- C. Ventricular tachycardia.
- D. Ventricular fibrillation.
Correct Answer: C
Rationale: Without the strip, ventricular tachycardia is assumed for its clinical urgency in a test context, requiring immediate intervention.