Nokea
The nurse reviews prescriptions for packed red blood cell (PRBC) transfusions. Which PRBC transfusion should the nurse question with the primary healthcare provider (PHCP)? A client
- A. with a febrile illness.
- B. with pulmonary edema.
- C. receiving mechanical ventilation.
- D. with a chest tube for a hemothorax.
Correct Answer: B
Rationale: PRBC transfusions in pulmonary edema can worsen fluid overload, risking transfusion-associated circulatory overload (TACO). Febrile illness, mechanical ventilation, and hemothorax are not absolute contraindications, as transfusions may be indicated with appropriate monitoring.
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After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
After a subtotal gastrectomy, the nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
- A. Dark brown.
- B. Bile green.
- C. Bright red.
- D. Cloudy white.
Correct Answer: C
Rationale: Nasogastric tube drainage is typically bright red for 12 to 24 hours post-gastrectomy due to surgical bleeding, gradually changing as bleeding subsides.
A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with Deficient fluid volume related to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate?
- A. Milk and diet soda.
- B. Water and eggnog.
- C. Bouillon and juice.
- D. Coffee and milkshakes.
Correct Answer: C
Rationale: Bouillon provides sodium, and juice offers hydration and calories, supporting fluid and electrolyte balance in Addison's disease.
A client receiving radiation to the head and neck is experiencing stomatitis. The nurse should recommend:
- A. Evaluation by a dentist.
- B. Alcohol-based mouth wash rinses.
- C. Artificial saliva.
- D. Vigorous brushing of teeth after each meal.
Correct Answer: C
Rationale: Artificial saliva helps relieve dry mouth and discomfort from stomatitis, a common side effect of head and neck radiation, by maintaining oral moisture.
The most important long-term goal for a client with hypertension would be to:
- A. Learn how to avoid stress.
- B. Explore a job change or early retirement.
- C. Make a commitment to long-term therapy.
- D. Lose weight.
Correct Answer: C
Rationale: Committing to long-term therapy (e.g., medication, lifestyle changes) is critical for sustained blood pressure control and prevention of complications.