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Within 20 minutes of the start of transfusion, the client develops a sudden fever. What is the nurse’s first action?
- A. Force fluids
- B. Increase the flow rate of IV fluids
- C. Continue to monitor the vitals signs
- D. Stop the transfusion
Correct Answer: D
Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.
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The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
- A. Assigning clinical cues
- B. Defining characteristics
- C. Diagnostic reasoning NursingStoreRN
- D. Diagnostic labeling
Correct Answer: C
Rationale: The correct answer is C: Diagnostic reasoning. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions.
A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis.
B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis.
D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.
The physician prescribes didanosone (ddl [Videx]), 200mg PO every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine ,AZT [Retrovir]). Which condition in the client’s history warrants cautious of this drug?
- A. Peripheral neuropathy
- B. Hypertension
- C. Diabetes mellitus
- D. Asthma
Correct Answer: A
Rationale: The correct answer is A: Peripheral neuropathy. Didanosine (ddl) can cause peripheral neuropathy as a side effect, which can exacerbate existing neuropathy. The client's history of peripheral neuropathy warrants caution with this drug to prevent further nerve damage.
Incorrect choices:
B: Hypertension - Didanosine is not contraindicated in hypertension.
C: Diabetes mellitus - While monitoring blood sugar levels is important, didanosine does not directly affect diabetes.
D: Asthma - Didanosine does not have a significant impact on asthma.
In summary, the client's pre-existing peripheral neuropathy makes it important to exercise caution with didanosine to avoid worsening this condition.
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection.
Summary:
A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure.
C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention.
D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.
The nurse is developing a teaching plan for a patient. Which of the following is a modifiable risk factor for the development of hypertension? i.Race iv.Sedentary lifestyle ii.High cholesterol v.Age iii.Cigarette smoking
- A. 1 and 2
- B. 2, 3, 4 and 5
- C. 2, 3 and 4
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: 2, 3, and 4. High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for developing hypertension. High cholesterol can lead to atherosclerosis, increasing blood pressure. Smoking can constrict blood vessels, raising blood pressure. Sedentary lifestyle can lead to obesity and overall poor cardiovascular health, contributing to hypertension. Race and age are non-modifiable risk factors. Choice A is incorrect because it includes race, a non-modifiable factor. Choice B is incorrect because it includes age, which is also non-modifiable. Choice D is incorrect because it includes all factors, including non-modifiable ones.