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Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein
- B. The head and back are immobilized mechanically with a cervical collar and back support
- C. Traction with weights and pulleys is applied
- D. A turning frame is used EMERGENCY AND DISASTER NURSING SITUATION: A group of high school teenagers went camping to Sohoton this summer for one week. You are the nurse assigned to this camp. For the first three days, you were busy with several emergencies.
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
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Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
- A. Add any needed IV medication in the blood bag within one hour of planned infusion
- B. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
- C. Prime tubing of blood administration set with 0.9% NS solution, completely, filling filter
- D. Inadequate dietary intake
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing.
Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval.
Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused.
Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in making a nursing clinical decision. The nurse assesses the time of the last dressing change and compares it with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and validated data, leading to appropriate patient care.
Choice B is incorrect because it does not involve data validation. The decision is driven by increased pain and family requests, without verifying the underlying cause.
Choice C is incorrect as it involves responding to a patient's reported symptom (leg cramps), but it does not involve data validation in making the clinical decision.
Choice D is incorrect as it relies solely on the patient's report of decreased mobility without further data validation.
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: B
Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream.
Choices A, C, and D are incorrect:
A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein.
C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device.
D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.
After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:
- A. Bleeding in the liver caused by the liver biopsy.
- B. Perforation of the colon caused by the liver biopsy.
- C. An allergic reaction to the contrast media used during liver biopsy.
- D. Normal post procedural pain, with a change in the level of consciousness resulting from the preexisting fever.
Correct Answer: B
Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention.
Incorrect options:
A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain.
C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion.
D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.
Which of the following guidekines does not observe surgical asepisi in the operating room?
- A. sterile articles may touch other sterile articles or surface and remain sterile
- B. gowns of surgical team are considered sterile in front from the chest down to the bottom of the gown
- C. whenever a sterile barrier is breached, the area must be considered contaminated
- D. sterile drapes are used to create a sterile field
Correct Answer: A
Rationale: The correct answer is A because in surgical asepsis, sterile articles should not touch other sterile articles or surfaces to maintain sterility. Choice B is correct as surgical team gowns are sterile in front. Choice C is correct as any breach makes the area contaminated. Choice D is correct as sterile drapes create a sterile field.