Nokea
The nurse is preparing to administer a unit of red blood cells (RBCs) to an anemic client. From starting the infusion (puncturing the blood pack) to completion, infusion of the pack should occur within which time period?
- A. 8 hours
- B. 6 hours
- C. 4 hours
- D. 2 hours
Correct Answer: C
Rationale: RBC transfusions must be completed within 4 hours to minimize bacterial growth and ensure safety.
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The nursing assistant finds a client on the floor. Once the client is safe, which of the following should the nurse do next?
- A. document the event in the client's medical record only
- B. document the event in the client's medical record and file an incident report
- C. document the event in the client's medical record and have the nursing assistant file an incident report
- D. have the nursing assistant file an incident report
Correct Answer: B
Rationale: Falls require documentation in the medical record and an incident report to track safety issues and ensure follow-up.
The nurse is caring for a client diagnosed with C. diff. The client has soiled the bed and the nurse is preparing to change it. Which action by the nurse is correct in regard to handling soiled linens that have been exposed to C. diff?
- A. throw the linens in the trash can in the soiled utility room
- B. leave the dirty linens in a bag in the client's room until he is discharged
- C. place the items in a red biohazard bag and place them in the soiled utility room
- D. place the soiled linen in a regular dirty linen bag and place in the soiled utility room
Correct Answer: D
Rationale: C. diff-contaminated linens should be placed in a regular dirty linen bag, as they are processed with high-temperature washing to kill spores, not treated as biohazard waste.
A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
- A. monitor for bleeding.
- B. place the client on neutropenic precautions.
- C. limit visiting hours.
- D. encourage a diet high in iron.
Correct Answer: A
Rationale: Thrombocytopenia (platelets <150,000) increases bleeding risk. Monitoring for bleeding (e.g., bruising, petechiae) is the priority.
Following femoral catheterization for percutaneous coronary intervention (PCI), the client has increasing pain in the catheterization site, and the nurse notes visible edema and induration surrounding the site. The nurse suspects a hematoma and notifies the physician. Which of the following interventions does the nurse anticipate? Select all that apply.
- A. Apply pressure to the site.
- B. Mark margins of edematous, indurated area.
- C. Monitor hemoglobin and hematocrit.
- D. Maintain bedrest.
- E. Administration of clotting factors.
Correct Answer: A,B,C,D
Rationale: Hematoma management includes applying pressure (A), marking edema (B), monitoring hemoglobin/hematocrit (C), and maintaining bedrest (D). Clotting factors (E) are not typically needed.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.