Nokea
What is the most important step when preparing to administer a blood transfusion?
- A. Check if the client has a fever
- B. Ensure the blood type is compatible with the client
- C. Administer the blood via IV push
- D. Ensure the blood is warmed to body temperature
Correct Answer: B
Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.
You may also like to solve these questions
Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?
- A. Maintain two points of support on the floor at all times
- B. Use the cane on the weak side of the body
- C. Advance the cane and the strong leg simultaneously
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: A
Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.
Which of the following is the best intervention for managing dehydration?
- A. Administer antiemetics to prevent nausea
- B. Monitor fluid and electrolyte levels
- C. Encourage the client to drink more fluids
- D. Administer intravenous fluids
Correct Answer: B
Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.
How should a healthcare professional assess a patient with hyperkalemia?
- A. Monitor ECG and administer insulin
- B. Monitor blood glucose levels and provide fluids
- C. Monitor for muscle weakness and administer calcium gluconate
- D. Monitor electrolyte levels and provide potassium supplements
Correct Answer: A
Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels.
Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia.
Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia.
Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.
A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?
- A. Low birth weight
- B. Advanced maternal age
- C. Single parenthood
- D. Premature birth
Correct Answer: A
Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.
A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?
- A. Insert the suppository 1 cm into the rectum
- B. Insert the suppository 2 cm into the rectum
- C. Insert the suppository past the anal sphincters
- D. Insert the suppository using two fingers
Correct Answer: C
Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.