Nokea
Which of the following laboratory findings should the nurse expect following the transfusion?
- A. Increased platelets
- B. Increased Hct
- C. Decreased Hgb
- D. Decreased WBC count
Correct Answer: B
Rationale: The correct answer is B: Increased Hct. Following a transfusion, the nurse should expect an increase in hematocrit (Hct) levels due to the addition of packed red blood cells. This will result in an increase in the concentration of red blood cells in the blood, leading to a higher Hct value. The other choices are incorrect as: A) Increased platelets are not typically affected by a red blood cell transfusion, C) Decreased Hgb would not be expected as the purpose of the transfusion is to increase hemoglobin levels, and D) Decreased WBC count is unrelated to a red blood cell transfusion.
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The nurse observes blood on the child's dressing.Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm(1 in) below the percutaneous skin site
- B. Apply continuous pressure 2.5 cm(1 in) above the percutaneous skin site
- C. Apply continuous pressure 2.5 cm(1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm(1 in) above the percutaneous skin site
Correct Answer: B
Rationale: Continuous pressure above the site controls bleeding effectively.
Which of the following manifestations should the nurse expect?
- A. Shortness of breath
- B. Dizziness
- C. Epistaxis
- D. Headache
Correct Answer: B
Rationale: Dizziness reflects reduced circulating volume.
The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Petechiae and ecchymoses suggest thrombocytopenia warranting platelet count evaluation.
Which of the following actions should the nurse take?
- A. Monitor for the development of Koplik spots.
- B. Isolate the client from staff who are pregnant.
- C. Administer aspirin to the client
- D. Initiate airborne precautions
Correct Answer: B
Rationale: Pregnant women should avoid contact with individuals who have rubella due to the risk of congenital defects.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The correct answer is B: Palms of the hands. In dark-skinned individuals, cyanosis may not be as apparent in typical areas like lips or nail beds. Palms of the hands are a reliable location to assess for cyanosis as they have less melanin and blood vessels close to the surface, making cyanosis more visible. The other choices (A: Sacrum, C: Shoulders, D: Area of trauma) are not ideal locations to assess for cyanosis as they are less likely to show accurate signs due to differences in skin thickness, blood vessel distribution, and melanin content.