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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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Which of the following conditions may necessitate fluid restriction?
- A. Fever
- B. Chronic Obstructive Pulmonary Disease
- C. Renal Failure
- D. Dehydration
Correct Answer: C
Rationale: Renal failure often necessitates fluid restriction to prevent fluid overload. In renal failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to fluid accumulation in the body. Restricting fluid intake helps manage this condition by preventing further fluid buildup and complications such as edema and electrolyte imbalances.
A 38-year-old patient's vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?
- A. Respiratory rate only
- B. Temperature only
- C. Pulse rate and temperature
- D. Temperature and respiratory rate
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare provider reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3-month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The healthcare provider could be charged with:
- A. Defamation
- B. Assault
- C. Battery
- D. Malpractice
Correct Answer: D
Rationale: The scenario described involves a breach of duty by the healthcare provider to properly supervise the infant, resulting in harm. This failure to meet the standard of care falls under the category of malpractice, which refers to professional negligence or misconduct. Malpractice specifically applies to situations where a healthcare provider's actions or omissions deviate from the accepted standard of care, causing harm to a patient. In this case, the nurse's lack of supervision leading to the infant falling off the scale and sustaining a skull fracture would be considered malpractice.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.
All of the following statements are true about donning sterile gloves except:
- A. The first glove should be picked up by grasping the inside of the cuff.
- B. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
- C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist.
- D. The inside of the glove is considered sterile.
Correct Answer: D
Rationale: When donning sterile gloves, it is essential to maintain sterility. The correct way to don sterile gloves includes grasping the outside of the cuff to put on the first glove and inserting the gloved fingers under the cuff outside the glove to put on the second glove. Adjustments should be made by sliding the fingers under the sterile cuff. It is crucial to remember that once the inside of the glove is touched during the donning process, it is no longer considered sterile.