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What are the nursing implications associated with administering blood and blood products to a client who has a blood type of B negative?
- A. The nurse must be knowledgeable about the fact that this client has A and B agglutinins and lacks the Rh factor
- B. The nurse must be knowledgeable about the fact that this client has B and O agglutinins and lacks the Rh factor
- C. The nurse must be knowledgeable about the fact that this client has B agglutinins and lacks the Rh factor
- D. The nurse must be knowledgeable about the fact that this client has A agglutinins and lacks the Rh factor
Correct Answer: C
Rationale: B negative blood type has anti-A agglutinins (antibodies against A antigen) and lacks the Rh factor, requiring careful matching to avoid transfusion reactions.
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A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?
- A. Respiratory acidosis.
- B. Respiratory alkalosis.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: A
Rationale: COPD with pneumonia can impair gas exchange, leading to CO2 retention and respiratory acidosis.
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which one of the following results indicates the presence of inflammation?
- A. Decreased sedimentation rate
- B. Thrombocytopenia
- C. Leukocytosis
- D. Erythrocytosis
Correct Answer: C
Rationale: Leukocytosis, an elevated white blood cell count, indicates inflammation or infection. Decreased sedimentation rate, thrombocytopenia, and erythrocytosis are not specific to inflammation.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about foot care. Which of the following instructions should be included? Select all that apply.
- A. Inspect feet daily for cuts or sores.
- B. Wear well-fitting shoes.
- C. Soak feet in hot water daily.
- D. Apply lotion between the toes.
- E. Trim toenails straight across.
Correct Answer: A, B, E
Rationale: Daily inspection, well-fitting shoes, and straight toenail trimming prevent complications. Hot water and lotion between toes increase infection risk.
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hyponatremia.
- D. Hypercalcemia.
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring close monitoring.