Nokea
What is the first step when administering a blood transfusion?
- A. Warm the blood to body temperature
- B. Verify the client's blood type before administration
- C. Administer the blood through an IV push
- D. Administer diuretics before the transfusion
Correct Answer: B
Rationale: The correct answer is to verify the client's blood type before administration. This step is crucial to ensure compatibility and prevent adverse reactions such as hemolytic transfusion reactions. Warming the blood to body temperature (Choice A) is not the first step and is not typically done during blood transfusions. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow infusion. Administering diuretics before the transfusion (Choice D) is unnecessary and not a standard practice when initiating a blood transfusion.
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The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
- A. Take the client to the dining room with 1:1 supervision
- B. Inform the client they may go to the dining room when they control their behavior
- C. Hold the meal until the client is able to come out of seclusion
- D. Serve the meal to the client in the seclusion room
Correct Answer: D
Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.
The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
- A. Request an occupational therapy consult to determine the need for assistive devices
- B. Assign assistive personnel to perform self-care tasks for the client
- C. Instruct the client to focus on gradually resuming self-care tasks
- D. Ask the client if a family member is available to assist with his care
Correct Answer: C
Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.
What are common risk factors for urinary tract infections (UTIs)?
- A. Poor hygiene and dehydration
- B. Increased sexual activity and pregnancy
- C. Use of urinary catheters and prolonged bed rest
- D. Family history and obesity
Correct Answer: A
Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.
A client has developed phlebitis at the IV site. What is the next step the nurse should take?
- A. Administer an anti-inflammatory medication
- B. Discontinue the IV and notify the provider
- C. Apply a cold compress over the IV site
- D. Increase the IV flow rate to prevent dehydration
Correct Answer: B
Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.
What are the differences between viral and bacterial infections?
- A. Viral infections often cause fatigue and body aches
- B. Bacterial infections often cause high fever and localized pain
- C. Viral infections are treated with antibiotics
- D. Bacterial infections are usually self-limiting
Correct Answer: A
Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.