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The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Obtain the client's weight
- B. Ensure ABO type compatibility
- C. Infuse the platelets over 2 to 4 hours
- D. Verify completed consent for platelet transfusion
- E. Obtain pre-transfusion vital signs
Correct Answer: B,D,E
Rationale: Ensuring ABO compatibility prevents transfusion reactions, verifying consent ensures legal and ethical standards, and obtaining pre-transfusion vital signs establishes a baseline for monitoring. Platelet infusions are typically rapid (15–30 minutes), not 2–4 hours, and weight is not routinely required unless dosing is weight-based.
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A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care?
- A. Relieving pain.
- B. Preserving joint function.
- C. Maintaining usual ways of accomplishing tasks.
- D. Preventing joint deformity.
Correct Answer: C
Rationale: During the acute phase, relieving pain, preserving joint function, and preventing deformity are critical to manage inflammation and prevent long-term damage. Maintaining usual ways of accomplishing tasks is less urgent.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
- A. Expected common adverse effects.
- B. Hypersensitivity reaction.
- C. Possible habituating effect.
- D. Hemorrhage from gastrointestinal irritation.
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
- A. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site.
- B. Verbally ask the client to state his name, surgical site, and procedure.
- C. Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports.
- D. Call a 'time-out' in the operating room to have the surgeon verify the correct knee before making the incision.
- E. Show the client an anatomic model of the surgery site.
Correct Answer: A,B,C,D
Rationale: To prevent wrong-site surgery, the surgeon marks the site (A), the client verifies identity and procedure (B), records are checked (C), and a time-out confirms the site (D). Showing a model (E) is educational but not a standard safety measure.
The nurse is reviewing a client's chart and notes a discrepancy in the TPN order. Which action should the nurse take first?
- A. Adjust the infusion rate to match the order.
- B. Contact the prescribing physician for clarification.
- C. Continue the current infusion rate.
- D. Document the discrepancy in the client's chart.
Correct Answer: B
Rationale: Contacting the prescribing physician for clarification is the first action to resolve a discrepancy in a TPN order, ensuring safety and accuracy. Adjusting the rate, continuing the current rate, or documenting without clarification risks errors. CN: Safety and infection control; CL: Synthesize
The nurse is observing a student nurse administer eyedrops, as shown in the fi gure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client’s eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.