Nokea
The nurse knows that hemolytic to blood transfusions occur most often when the first milliliters of the infusion.
- A. 125
- B. 50
- C. 100
- D. 75
Correct Answer: B
Rationale: Hemolytic reactions strike early 50 mL often triggers as mismatched blood clashes, a rapid antigen-antibody storm. Later volumes (75-125) build on it; 100's common but not peak. Nurses watch those first drops, stopping at 50 mL's hint of fever or pain, a tight window in this transfusion trap.
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Appropriate statements concerning radiology and trauma interventional radiology include:
- A. To rule out injury of the cervical spine in the unconscious patient, application of a protocol involving a computed tomography (CT) scan to the neck is recommended.
- B. A FAST (Focused Assessment with Sonography for Trauma) scan is a specific investigation for assessment of intraperitoneal bleeding.
- C. In a patient who is persistently hypotensive in the emergency department despite adequate fluid resuscitation, radiological interventions to treat bleeding caused by a pelvic fracture are not recommended.
- D. Interventional radiology has a role in the management of injuries to the liver, kidney and spleen.
Correct Answer: A
Rationale: Trauma radiology optimizes diagnosis and intervention. CT is the gold standard for cervical spine assessment in unconscious patients, per NICE guidelines, offering high sensitivity for fractures/ligamentous injury versus plain films. FAST scans detect free fluid (e.g., blood) intraperitoneally but lack specificity positive findings need confirmation (e.g., CT). Persistent hypotension with pelvic fracture warrants interventional radiology (e.g., embolization), not dismissal contrary to the statement. Interventional radiology manages solid organ injuries (liver, kidney, spleen) via embolization, reducing surgical need. Staffing in radiology matches theatre for critical cases. CT's diagnostic precision in cervical spine trauma ensures timely, accurate management, critical in unconscious patients where clinical exam is unreliable.
The nurse is caring for a client with mitral regurgitation. Which of the following would the nurse anticipate the client to develop if left untreated?
- A. Left-sided heart failure
- B. Right-sided heart failure
- C. Renal failure
- D. Myocardial ischemia
Correct Answer: A
Rationale: Mitral regurgitation backflows blood into the left atrium, hiking pressure and volume untreated, it overburdens the left ventricle, leading to left-sided heart failure. Pulmonary congestion follows, with dyspnea and edema, a direct consequence of this valve flaw. Right-sided failure stems from downstream effects or separate causes, not primary here. Renal failure or ischemia might complicate advanced disease, but left-sided failure's progression is the immediate risk, rooted in mitral dysfunction's mechanics. Nurses anticipate this, monitoring for early signs like crackles, ensuring timely intervention to halt this predictable cardiac cascade.
A nurse sets an infusion pump to infuse 1 L of D5NS at the rate of $100 \mathrm{~mL} / \mathrm{hr}$. How many hours will it take to complete the infusion?
- A. 8
- B. 10
- C. 12
- D. 14
Correct Answer: B
Rationale: Math rules IV timing 1 L (1000 mL) at 100 mL/hr divides to 10 hours, a straightforward calc nurses nail for fluid planning. Missteps like 8 or 12 flub the rate; 14's way off. Precision here ensures hydration or med delivery hits the mark, a basic skill keeping care on track.
A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
- A. Call the client at home the next day to review teaching.
- B. Give the client information about a cancer support group.
- C. Provide all the preoperative instructions in writing.
- D. Reassure the client that surgery will be over soon.
Correct Answer: A
Rationale: A new cancer diagnosis combined with the urgency of surgery in three days can overwhelm a client, impairing their ability to process and retain preoperative instructions due to emotional stress and anxiety. Calling the client the next day to review teaching allows the nurse to reinforce key points, answer questions, and ensure comprehension when the client may be calmer and more receptive. While providing written instructions is helpful, it assumes literacy and may not address immediate confusion or emotional barriers. Offering support group information is valuable for long-term coping but doesn't prioritize the urgent need for surgical preparation. Reassuring the client that surgery will be over soon dismisses their concerns and doesn't enhance understanding. The follow-up call is the best action, as it aligns with adult learning principles and nursing's role in ensuring informed consent and readiness, reducing perioperative risks and anxiety for the client.
Risk factors for developing COPD do not include:
- A. Smoking - passive or active
- B. Age
- C. High fat diet
- D. Indoor and outdoor air pollution
Correct Answer: C
Rationale: COPD's lung wreckers smoking, age, pollution scar airways, no dodge. High fat diet fattens, not chokes lungs; it's metabolic, not respiratory. Nurses target smoke and smog, not butter, a chronic breath stealer's true culprits.