Nokea
Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?
- A. Fever
- B. Red urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.
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The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately
- B. Record the finding and give the infant's injection
- C. Recognize that the finding is a variation of normal
- D. Check both eyes for the presence of the red reflex
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or cataracts, requiring immediate reporting to the physician for further evaluation.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.
The nurse is caring for a client whose native language is Korean; he speaks only a few words of English. The health care provider has determined that the client needs to undergo a coronary artery bypass graft. Which is the appropriate action by the nurse?
- A. ask the client's spouse to give consent for the procedure before explaining it to the client
- B. ask the client's spouse to translate for the health care provider and explain the procedure to the client
- C. communicate with the client by showing pictures of the intended surgery while a family member translates
- D. request a licensed translator to interpret for the health care provider and client during the conversation
Correct Answer: D
Rationale: A licensed translator ensures accurate communication and informed consent, adhering to ethical and legal standards.
What is the responsibility of the nurse in obtaining an informed consent for surgery?
- A. Describing in a clear and simply stated manner what the surgery will involve
- B. Explaining the benefits, alternatives, and possible risks and complications of surgery
- C. Using the nurse/client relationship to persuade the client to sign the operative permit
- D. Providing the informed consent for surgery and witnessing the client's signature
Correct Answer: D
Rationale: The nurse's role is to witness the client's signature and ensure the consent form is completed, not to explain the procedure.
The nurse is assessing a client with suspected glomerulonephritis. Which of the following findings would the nurse expect?
- A. Clear, pale urine.
- B. Hematuria and proteinuria.
- C. Polyuria and dilute urine.
- D. Absence of edema.
Correct Answer: B
Rationale: hematuria and proteinuria are hallmark signs of glomerulonephritis due to glomerular damage