Nokea
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client’s temperature before, during, and after transfusion
- B. Documenting the client’s temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client’s temp with the temp of the blood
Correct Answer: A
Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction.
Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.
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Which of the following examples of client data needs to be validated?
- A. A client has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a client with a respiratory infection documents fever and chills.
- D. A client in a nursing home states that she is unable to eat the food being served.
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight.
- Choice B is about interpreting physical signs, not client data validation.
- Choice C involves documenting objective findings, not validating client information.
- Choice D pertains to a client's complaint, not necessarily requiring validation.
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
- A. Report the ulcer to the admitting care provider.
- B. Teach the man about STD prevention.
- C. Ask the man if he has a history of syphilis.
- D. Clean the ulcer; reporting is not necessary because an STD is unlikely in a man this age.
Correct Answer: A
Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.
For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. “Client verbalizes feelings of anxiety.”
- B. “Client doesn’t guess at prognosis.”
- C. “Client uses any effective method to reduce tension.”
- D. “Client stops seeking information.”
Correct Answer: C
Rationale: The correct answer is C because it focuses on the client actively engaging in reducing tension, which is essential in managing anxiety. This outcome is measurable and client-centered.
A: Verbalizing feelings is important, but it does not necessarily lead to reduction in anxiety.
B: Not guessing prognosis is helpful, but it does not address the active management of anxiety.
D: Stopping seeking information may not be beneficial as knowledge can empower the client in coping with the diagnosis.
For a patient receiving furosemide, the nurse evaluates the medication as being effective if which of the following effects occurs?
- A. Urine output increased
- B. Heart rate increased
- C. Serum potassium decreased
- D. Pulse pressure increased
Correct Answer: A
Rationale: The correct answer is A: Urine output increased. Furosemide is a loop diuretic that works by increasing urine output, thus helping to reduce fluid volume in the body. This effect is crucial in managing conditions like heart failure and edema. Increased urine output indicates that the medication is working as intended.
Choice B: Heart rate increased is incorrect as furosemide does not directly affect heart rate.
Choice C: Serum potassium decreased is incorrect as furosemide can lead to potassium loss, but this is not the primary indicator of its effectiveness.
Choice D: Pulse pressure increased is incorrect as furosemide does not typically impact pulse pressure.
Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5’3” in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The correct answer is B because the patient's Body Mass Index (BMI) indicates obesity, putting them at higher risk for surgical complications. Obesity is associated with increased risks of infections, delayed wound healing, respiratory issues, and cardiovascular problems post-surgery. Monitoring this patient closely is crucial.
Choice A is less likely to have increased surgical complications due to age and condition. Choice C, a 12-year-old, is less likely to have significant surgical complications compared to adults. Choice D, a 17-year-old with gallstones, may have risks but the BMI of the patient in choice B indicates a higher risk.