Nokea
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
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Sensorineural hearing loss results from which of the following conditions?
- A. Presence of fluid and cerumen in the external canal.
- B. Sclerosis of the bones of the middle ear.
- C. Change to the cochlear or vestibulocochlear nerve.
- D. Emotional disturbance resulting in a functional hearing loss.
Correct Answer: C
Rationale: Sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve, affecting the inner ear or neural pathways.
One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:
- A. Arteries
- B. Capillaries
- C. Lymphatics
- D. Veins
Correct Answer: A
Rationale: Anxiety can trigger sympathetic nervous system activation, causing arterial vasoconstriction, which worsens ischemia in PVD. Reducing anxiety helps maintain arterial dilation and blood flow. Capillaries, lymphatics, and veins are less affected by this mechanism.
The client asks the nurse, 'Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?' The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
- A. The need to remove as much of the leg as possible
- B. The adequacy of the blood supply to the tissues
- C. The ease with which a prosthesis can be fitted
- D. The client's ability to walk with a prosthesis
Correct Answer: B
Rationale: The level of amputation depends primarily on the adequacy of blood supply to the tissues, as determined intraoperatively. Sufficient perfusion is necessary for healing and preventing further necrosis. Removing excess tissue, prosthesis fitting, or walking ability are secondary considerations.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
- A. Taking vital signs every 2 hours.
- B. Measuring urine output hourly.
- C. Assessing arterial blood gas values every other day.
- D. Checking blood glucose levels.
Correct Answer: B
Rationale: Diabetes insipidus, often caused by head injury, leads to excessive dilute urine output. Hourly urine output measurement is the most effective way to detect this condition early. Vital signs, blood gases, and glucose levels are less specific for this diagnosis.