Nokea
Which of the following actions is appropriate when administering a blood transfusion?
- A. Verify patient identity
- B. Administer medication
- C. Monitor vital signs
- D. Start blood transfusion without verification
Correct Answer: A
Rationale: Verifying the patient's identity is a critical step when administering a blood transfusion to ensure that the correct blood product is given to the right patient. This process helps prevent errors and enhances patient safety. Choice B, 'Administer medication,' is incorrect because the focus during a blood transfusion should be on ensuring the correct blood product is administered. Choice C, 'Monitor vital signs,' is also important but comes after verifying the patient's identity. Choice D, 'Start blood transfusion without verification,' is incorrect and unsafe as patient identification verification is essential prior to starting any medical procedure, especially one as important as a blood transfusion.
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What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?
- A. Administer anticoagulants
- B. Encourage ambulation
- C. Apply compression stockings
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.
What is the priority nursing action for a patient with respiratory distress?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer bronchodilators
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serosanguineous wound drainage
- B. Heart rate of 90/min
- C. Urine output of 30 mL/hr
- D. Temperature of 37.3°C (99.1°F)
Correct Answer: C
Rationale: A urine output of 30 mL/hr is significantly low and indicates possible renal impairment or inadequate perfusion to the kidneys, which are critical for postoperative recovery. In this situation, decreased urine output could lead to fluid and electrolyte imbalances, affecting the client's overall condition. The nurse should report this finding promptly to the healthcare provider for further evaluation and intervention. Serosanguineous wound drainage is a normal finding in the early postoperative period and does not typically warrant immediate concern. A heart rate of 90/min is within the normal range and may be expected in a postoperative client due to the stress response. A temperature of 37.3°C (99.1°F) is slightly elevated but not a concerning finding in isolation postoperatively.
A client at risk for osteoporosis is being taught by a nurse about dietary measures to increase calcium intake. Which of the following foods should the nurse recommend?
- A. Carrots
- B. Cottage cheese
- C. Bananas
- D. Broccoli
Correct Answer: D
Rationale: The correct answer is D: Broccoli. Broccoli is high in calcium, making it a suitable recommendation for clients at risk for osteoporosis. Carrots, Cottage cheese, and Bananas are not significant sources of calcium compared to broccoli, and therefore, they are not the best choices to increase calcium intake.
What is the most important nursing action for a patient presenting with confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological assessment
Correct Answer: A
Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.