Nokea
What is an important consideration when administering a blood transfusion?
- A. Ensure the blood is compatible with the recipient's blood type
- B. Warm the blood to body temperature before administration
- C. Check the blood for clots before administration
- D. Ensure the recipient eats before the transfusion
Correct Answer: A
Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.
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A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?
- A. The client's urination habits.
- B. The client's financial information.
- C. The client's social history.
- D. The client's current level of mobility.
Correct Answer: D
Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.
How should a healthcare provider assess a patient with potential diabetic ketoacidosis (DKA)?
- A. Monitor blood glucose and check for ketones in urine
- B. Administer insulin and provide fluids
- C. Administer potassium and check for electrolyte imbalance
- D. Administer sodium bicarbonate and monitor urine output
Correct Answer: A
Rationale: Correct answer: To assess a patient with potential diabetic ketoacidosis (DKA), healthcare providers should monitor blood glucose and check for ketones in the urine. Elevated blood glucose levels and the presence of ketones in urine are indicative of DKA. Choice B is incorrect because administering insulin and providing fluids are treatments for DKA rather than assessment measures. Choice C is incorrect as administering potassium and checking for electrolyte imbalance are interventions related to managing DKA complications, not initial assessment. Choice D is incorrect because administering sodium bicarbonate and monitoring urine output are not primary assessment actions for DKA.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct Answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.
What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct Answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.
A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?
- A. Turn the client onto their left side
- B. Irrigate the NG tube with sterile water
- C. Increase the suction pressure to relieve the blockage
- D. Remove the NG tube and replace it with a new one
Correct Answer: B
Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.