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When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
- A. Send freshly-collected urine samples to the laboratory.
- B. Return the remainder of the blood component unit to the blood bank.
- C. Return the intravenous administration set to the blood bank.
- D. Alert Risk Management about the incident.
- E. Report the incident to the Infection Control Manager.
Correct Answer: A,B
Rationale: After a transfusion reaction, the nurse should send urine samples to check for hemolysis and return the remaining blood unit to the blood bank for analysis. The IV administration set is not typically returned, and while Risk Management and Infection Control may be notified, these are not immediate actions.
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Several clients have come to the emergency department after a possible bioterrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply.
- A. Violent vomiting.
- B. Severe diarrhea.
- C. Abdominal pain.
- D. Sensory neuropathy.
- E. Persistent cough.
Correct Answer: A,B,C
Rationale: Arsenic poisoning typically presents with acute gastrointestinal symptoms such as violent vomiting, severe diarrhea, and abdominal pain due to its toxic effects on the digestive system. Sensory neuropathy and persistent cough are less common immediate symptoms.
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises?
- A. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange.
- B. Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery.
- C. Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated.
- D. Deep breathing expands the alveoli and increases the lung surface available for ventilation.
Correct Answer: D
Rationale: Deep breathing expands alveoli, increasing lung surface for ventilation and preventing atelectasis post-thoracotomy. It does not elevate the diaphragm, increase blood flow, or control airflow to prevent hyperinflation.
The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse?
- A. Inserts the needle, bevel up at a 15-degree angle
- B. Instructs the client that the test will be read in 48-72 hours
- C. Selects a site 3 to 4 finger widths below the antecubital space
- D. Administers the test using a 20-gauge needle, 2 inches long
Correct Answer: D
Rationale: A PPD test requires a 26- or 27-gauge needle, 1/2 inch long, for intradermal administration.
The client with a fractured femur is upset and agitated about her injury and its treatment. She says, 'How can I stay like this for weeks? I can't even move!' Which of the following is the most appropriate nursing diagnosis?
- A. Impaired physical mobility related to traction.
- B. Ineffective coping related to prolonged immobility.
- C. Deficient diversional activity related to prolonged hospitalization.
- D. Activity intolerance related to impaired mobility.
Correct Answer: B
Rationale: Ineffective coping reflects the client's emotional distress and agitation due to immobility.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.