Nokea
The nurse is teaching a client who is scheduled for a transfusion of one unit of packed red blood cells (PRBCs). Which of the following information should the nurse include?
- A. A baseline weight will be taken before the start of the transfusion.
- B. I will be with you during the transfusion's first fifteen minutes.
- C. You will need to provide a urine sample at the end of the transfusion.
- D. Please complete the required surgical consent before the transfusion.
Correct Answer: B
Rationale: The nurse must stay with the client during the first 15 minutes of a PRBC transfusion to monitor for acute reactions, which are most likely to occur early. Baseline weight is relevant for fluid overload risk, not routine. Urine samples are not standard, and surgical consent is not required for transfusions.
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Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible adverse effect of this drug?
- A. Constipation.
- B. Bradycardia.
- C. Diplopia.
- D. Restlessness.
Correct Answer: D
Rationale: Pseudoephedrine is a sympathomimetic that can cause central nervous system stimulation, leading to restlessness. Constipation, bradycardia, and diplopia are not common adverse effects of this medication.
A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
- A. Medication therapy.
- B. Diet modification.
- C. Activity restrictions.
- D. Dental care.
Correct Answer: A
Rationale: Medication therapy (e.g., anticoagulants, diuretics) is critical to manage symptoms and prevent complications like thromboembolism in mitral stenosis.
A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse maladaptive coping?
- A. œI will be glad to have my jaw fixed because my wife thinks I do not look like myself.'
- B. œI am somewhat afraid to have the surgery but feel OK about it.'
- C. œMy wife will help me, but I don't think I will need that much help.'
- D. œI am ready to get this over with.'
Correct Answer: A
Rationale: The statement about the wife's perception suggests the client's motivation is external and may reflect poor self-image or reliance on others' opinions, indicating maladaptive coping. The other statements show acceptance, realistic fear, or confidence, which are more adaptive.
Several clients who work in the same building are brought to the emergency department. They all common to the patient's condition. Including fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate?
- A. Contact isolation with double-gloving and shoe covers.
- B. Respiratory isolation with positive pressure rooms.
- C. Enteric precautions.
- D. Reverse isolation.
Correct Answer: A
Rationale: Symptoms suggest a hemorrhagic fever (e.g., Ebola), requiring contact isolation with enhanced precautions like double-gloving and shoe covers to prevent transmission.
The family members caring for a 72-year-old client who is near death from colon cancer are concerned about dehydration. What should the nurse tell them about dehydration at end of life?
- A. The physician will make the decision regarding hydration therapy.
- B. Dehydration may prolong the dying process.
- C. Hydration is used only in extreme situations of dehydration.
- D. Dehydration is expected during the dying process.
Correct Answer: D
Rationale: Dehydration is a natural part of the dying process and is often not treated aggressively in hospice care, as it may not cause discomfort and can reduce symptoms like edema.