Nokea
Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?
- A. Fever
- B. Red colored urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath may indicate an acute transfusion reaction (e.g., TRALI) during bone marrow transplantation, requiring immediate action. Fever (A), red urine (B), and hypertension (C) are less specific or expected.
You may also like to solve these questions
The client is admitted with a diagnosis of gestational diabetes. Which dietary recommendation is most appropriate?
- A. Low-carbohydrate,high-protein diet
- B. High-fat,low-calorie diet
- C. Low-protein,high-carbohydrate diet
- D. High-calorie,low-fat diet
Correct Answer: A
Rationale: A low-carbohydrate high-protein diet helps maintain stable blood glucose levels in gestational diabetes reducing the risk of hyperglycemia. High-fat high-carbohydrate or high-calorie diets are less suitable.
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
- A. Prepare an injection of vitamin K
- B. Irrigate the urinary catheter with 50 mL of normal saline
- C. Offer the client additional oral fluids
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
The client is admitted with a diagnosis of preterm labor. Which symptom is most characteristic?
- A. Uterine contractions
- B. Fetal macrosomia
- C. Maternal fever
- D. Painless vaginal bleeding
Correct Answer: A
Rationale: Uterine contractions (regular frequent) are the hallmark of preterm labor occurring before 37 weeks. Fetal macrosomia maternal fever and painless bleeding are not characteristic.
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
- A. Iron-deficiency anemia
- B. Physiological anemia
- C. Fatigue due to stress
- D. No problem indicated
Correct Answer: A
Rationale: This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. The client's values are below levels for physiological anemia. The client is fatigued because of a low hemoglobin level. Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
The nurse is caring for a client with a history of atrial fibrillation. Which medication is most likely to be prescribed to prevent thromboembolism?
- A. Warfarin (Coumadin)
- B. Aspirin
- C. Clopidogrel (Plavix)
- D. Heparin
Correct Answer: A
Rationale: Warfarin is commonly prescribed for atrial fibrillation to prevent thromboembolism by maintaining anticoagulation (target INR 2–3). Aspirin and clopidogrel are less effective, and heparin is used short-term.