Nokea
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: A
Rationale: The correct answer is A. Blood type A is considered the rarest because it is less common in the general population compared to other blood types. The rarity of blood type A is due to the combination of genetic factors that determine blood type. In contrast, blood types B and O are more common in the population, while blood type AB is considered the universal recipient type and is therefore not the rarest. Blood type A is less prevalent, making it the correct answer in this scenario.
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The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, “I know I am not going to wake up after surgery.” Which of the following actions should the nurse take?
- A. Reassure patient everything will be all right
- B. Explain national surgery death rate
- C. Inform the registered nurse
- D. Ask family to comfort the patient
Correct Answer: C
Rationale: The correct answer is C: Inform the registered nurse. This is the best course of action as the LPN should escalate the situation to a higher level of care by involving the registered nurse who can further assess the patient's concerns and provide appropriate interventions.
A. Reassuring the patient may not address the underlying fear and may not be sufficient to alleviate their anxiety.
B. Providing statistics about surgery death rates may further escalate the patient's fears and anxiety, causing more harm than good.
D. Involving the family to comfort the patient may not address the patient's specific concerns and may not be within the family's scope of understanding or expertise to effectively address the situation.
Informing the registered nurse allows for a more comprehensive assessment and appropriate intervention to address the patient's fears and concerns in a holistic manner.
To supplement a diet with foods high in potassium, the nurse should recommend the addition of:
- A. Fruits such as bananas
- B. Milk and yogurt
- C. Green leafy vegetables
- D. Nuts and legumes
Correct Answer: A
Rationale: The correct answer is A: Fruits such as bananas. Bananas are high in potassium, which is essential for various bodily functions like muscle contractions and maintaining fluid balance. Fruits are a natural source of potassium and are easily incorporated into the diet. Milk and yogurt (B) are good sources of calcium, not potassium. Green leafy vegetables (C) are nutritious but may not provide as much potassium as fruits. Nuts and legumes (D) are good sources of protein and healthy fats but are not as rich in potassium as fruits like bananas.
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client’s temperature before, during, and after transfusion
- B. Documenting the client’s temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client’s temp with the temp of the blood
Correct Answer: A
Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction.
Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.