Nokea
The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?
- A. Emboli formation.
- B. Fluid volume overload.
- C. Red blood cell hemolysis.
- D. Allergic reaction.
Correct Answer: B
Rationale: A slow infusion rate (60 mL/hour) prevents fluid volume overload, especially in clients at risk post-trauma. Emboli, hemolysis, and allergic reactions are less directly related to infusion rate.
You may also like to solve these questions
A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure?
- A. You may feel a warm solution being wiped over your entire front from your neck down to your navel and out to your shoulders.'
- B. You will not feel the local anesthetic being applied because it will be sprayed on.'
- C. You will feel a pulling type of discomfort for a few seconds.'
- D. After the needle is removed, you will feel a bandage being applied around your chest.'
Correct Answer: C
Rationale: During sternal bone marrow aspiration, the client may feel a brief pulling or pressure sensation as the marrow is aspirated. The antiseptic solution is not applied over such a large area, local anesthetic is injected (not sprayed), and a bandage is applied to the site, not around the chest.
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below. Based on these results, the nurse should:
- A. Assess the client for bleeding
- B. Administer the medication
- C. Inform the physician
- D. Withhold the dose of Lovenox
Correct Answer: C
Rationale: Without specific lab results provided, the context implies abnormal values (e.g., low platelets or high INR) that increase bleeding risk with enoxaparin, a low-molecular-weight heparin. The nurse should inform the physician to evaluate the results before proceeding. Administering or withholding without consultation is unsafe, and assessing for bleeding is not the immediate action.
A 48-year-old client with cancer has been receiving 10 mg of I.V. morphine while hospitalized. In control, the nurse should administer which of the following doses of oral morphine?
- A. 25 mg.
- B. 30 mg.
- C. 40 mg.
- D. 10 mg.
Correct Answer: B
Rationale: The equianalgesic conversion from 10 mg I.V. morphine to oral morphine (1:3 ratio) is 30 mg, as oral morphine has lower bioavailability due to first-pass metabolism.
Which of the following characteristics would put a client at the greatest risk for impaired wound healing after abdominal surgery?
- A. Age 75 years.
- B. Age 30 years, with poorly controlled diabetes.
- C. Age 55 years, with myocardial infarction.
- D. Age 60 years, with peripheral vascular disease.
Correct Answer: B
Rationale: Poorly controlled diabetes impairs wound healing due to high glucose levels affecting immune response and tissue repair, posing a greater risk than age or other conditions listed.
Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis?
- A. Turn from side to side.
- B. Raise and lower the head.
- C. Raise the arm on the affected side over the head.
- D. Flex and extend the elbow on the affected side.
Correct Answer: C
Rationale: Raising the arm overhead prevents shoulder ankylosis (stiffness) by maintaining range of motion post-chest surgery. Other movements are less specific to shoulder mobility.