Nokea
Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.
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The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
- A. "You will need to accept the necessity for a quiet and inactive lifestyle."
- B. "Keep active, use stress reduction strategies, and avoid fatigue."
- C. "Follow good health habits to change the course of the disease."
- D. "Practice using the mechanical aids that you will need when future disabilities arise."
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management supports the client's quality of life and symptom control. Inactivity, changing disease course, or premature focus on aids are less appropriate.
A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
If the client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
- A. Review the negative effects of smoking on the body.
- B. Discuss the effects of passive smoking on environmental pollution.
- C. Establish the client's daily smoking pattern.
- D. Explain how smoking worsens high blood pressure.
Correct Answer: C
Rationale: Establishing the daily smoking pattern identifies triggers and habits, forming the basis for a tailored cessation plan.