Nokea
The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: C
Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.
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Which action should the nurse take first during the initial phase of implementation?
- A. Determine patient outcomes and goals.
- B. Prioritize patient’s nursing diagnoses.
- C. Evaluate interventions.
- D. Reassess the patient.
Correct Answer: D
Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.
. A client is admitted to the health care facility for evaluation for Addison’s disease. Which laboratory test result best supports a diagnosis of Addison’s disease?
- A. Blood urea nitrogen (BUN) level of
- B. Serum sodium level of 134 mEq/L
- C. Serum potassium level of 5.8 mEq/L
- D. Blood glucose level of 90 mg/dl
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Serum potassium level of 5.8 mEq/L) being the best to support a diagnosis of Addison's disease:
1. Addison's disease is characterized by adrenal insufficiency, leading to decreased aldosterone secretion.
2. Decreased aldosterone causes hyperkalemia due to impaired potassium excretion.
3. Elevated serum potassium levels above the normal range (3.5-5.0 mEq/L) are a classic finding in Addison's disease.
4. Therefore, a serum potassium level of 5.8 mEq/L strongly supports the diagnosis of Addison's disease.
Summary:
- Choice A (BUN level): BUN is not specific to Addison's disease and does not directly relate to adrenal function.
- Choice B (Serum sodium level): Hyponatremia is a common finding in Addison's disease, but it is not as specific as hyperkalemia.
- Choice D (Blood glucose level): Blood glucose
Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above Charles is a 76 year old retired professional golfer. He has recently been diagnosed as having Parkinson’s disease.
Correct Answer: D
Rationale: The correct answer is D because a disease process involving the sacral plexus can impact bladder function (choice A), sexual activity (choice B), and bowel management (choice C). The sacral plexus is responsible for innervating pelvic organs and lower limb muscles, so dysfunction in this area can lead to issues in these functions. Bladder problems can manifest as urinary retention or incontinence, sexual activity may be affected due to changes in sensation or muscle control, and bowel management can be disrupted leading to constipation or incontinence. Therefore, assessing all these areas is crucial to understand the full impact of the disease process on the individual's quality of life.
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
- A. 1, 2, 3, 4
- B. 3, 4, 1, 2
- C. 2, 3, 4, 1
- D. 4, 1, 2, 3
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.