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The physician has ordered 2 units of whole blood for a client following surgery. To provide for client safety, the nurse should:
- A. Obtain a signed permit for each unit of blood
- B. Use a new administration set for each unit transfused
- C. Administer the blood using a $Y$ connector
- D. Check the blood type and Rh factor three times before initiating the transfusion
Correct Answer: B
Rationale: Using a new administration set for each unit prevents contamination and ensures accurate delivery, enhancing transfusion safety.
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The charge nurse on a surgical unit incorporates an authoritative style of leadership. Which characteristics describe this style of leadership? Select all that apply.
- A. involves little planning
- B. motivates staff by coercion
- C. motivates staff by supporting their achievements
- D. involves communication flow down the chain of command
- E. includes group members in the decision-making process
Correct Answer: B, D
Rationale: Authoritative leadership involves top-down communication and can use coercion to motivate, focusing on control rather than collaboration or support.
A pediatric nurse volunteers at a health screening fair. The nurse examines a patient. Which of the following findings may be indicative of type 1 diabetes and require further investigation?
- A. stomach bloating, swollen lymph nodes, increased thirst
- B. sudden weight loss, blurry vision, muscle weakness
- C. sudden weight gain, ringing in the ears, difficulty sleeping
- D. feeling hungry all of the time, increased thirst, waking up at night to urinate
Correct Answer: D
Rationale: Type 1 diabetes presents with polyphagia, polydipsia, and polyuria (e.g., waking to urinate). Weight loss (B) is also common, but D is the most specific.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
- A. Altered nutrition
- B. Impaired communication
- C. Risk for injury/aspiration
- D. Altered urinary elimination
Correct Answer: C
Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.
The nurse is caring for a client with a wound with purulent, foul-smelling drainage. A wound culture is ordered. Which describes the correct collection technique?
- A. clean the wound with normal saline before obtaining specimen
- B. allow 24 hours for antibiotic therapy to take effect before sampling
- C. obtain the specimen from the drainage at the bottom of the wound
- D. culture the outer surface around the wound before collecting exudate
Correct Answer: A
Rationale: Cleaning the wound with saline removes surface contaminants, ensuring an accurate culture from viable tissue.
The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is:
- A. Inability to perform motor activities
- B. Complaints of double vision
- C. Restlessness
- D. Unequal pupil size
Correct Answer: C
Rationale: Restlessness is often an early sign of altered consciousness, indicating neurological changes before more severe symptoms appear.