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The nurse is transfusing one unit of packed red blood cells (PRBCs) to a client. The nurse initiated the transfusion at 1400. After completing the 1545 vital signs, the nurse should take which action? See the image below.
- A. Stop the transfusion
- B. Verify the blood product with another nurse
- C. Apply nasal cannula oxygen
- D. Document the findings and continue the transfusion
Correct Answer: D
Rationale: Without specific abnormal vital signs provided in the image, the nurse should document the findings and continue the transfusion if vital signs are stable, as this is standard practice after monitoring. Stopping the transfusion, verifying the product again, or applying oxygen require specific indications of a transfusion reaction or instability.
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Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
- A. Acute respiratory distress syndrome.
- B. Migraine-like headaches.
- C. Numbness in the right leg.
- D. Muscle spasms in the right thigh.
Correct Answer: A
Rationale: Fat embolism commonly presents with acute respiratory distress, a life-threatening complication of femoral fractures.
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply.
- A. Angel food cake.
- B. Banana.
- C. Dried fruit.
- D. Orange juice.
- E. Peppers.
Correct Answer: B,C,D
Rationale: Loop diuretics like furosemide cause potassium loss. Bananas (B), dried fruit (C), and orange juice (D) are potassium-rich, helping prevent hypokalemia.
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:
- A. Immerse her hands in cold water during an episode
- B. Wear light garments when the temperature gets below 50°F (10°C)
- C. Wear gloves when handling ice or frozen foods
- D. Live in a cold climate
Correct Answer: C
Rationale: Wearing gloves when handling ice or frozen foods prevents cold-induced vasospasm in Raynaud's. Cold water worsens symptoms, light garments are insufficient in cold temperatures, and living in a cold climate increases episode frequency.
The nurse is performing discharge education to an older adult diagnosed with cataracts. Which of the following statements indicates effective understanding?
- A. I may have to quit driving until I get the cataracts treated.'
- B. I should spend less time outdoors in the sun and plan more activities at night.'
- C. I will need to avoid activities that raise my intraocular pressure, such as bending at the waist.'
- D. I will have to be careful since my eyes won't move together.'
Correct Answer: A
Rationale: Cataracts can impair vision, making driving unsafe until treated. Sun exposure does not directly affect cataracts, intraocular pressure is not a primary concern, and eye movement misalignment is not typical.