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Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?
- A. Hemoglobinuria
- B. Chest pain
- C. Urticaria
- D. Distended neck veins
Correct Answer: A
Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.
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The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.
Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct Answer: D
Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.
When is the most appropriate time for obtaining a sputum specimen for culture?
- A. Early in the morning
- B. After the patient eats a light breakfast
- C. After aerosol therapy
- D. After chest physiotherapy
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct Answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.
Which of the following patients is at greatest risk for developing pressure ulcers?
- A. An alert chronic arthritic patient treated with steroids and aspirin
- B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
- C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.