Nokea
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Remaining with the client for at least 15-30 minutes after starting a blood transfusion is critical to monitor for acute transfusion reactions, such as hemolytic or allergic reactions.
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A client has primary health care provider instructions to take ibuprofen 0.4 g for mild pain. The medication bottle contains ibuprofen 200-mg tablets. How many tablets will the nurse instruct the client to take for each dose? Fill in the blank. tablets
Correct Answer: 2
Rationale: To determine the number of tablets, divide the prescribed dose by the strength per tablet: 0.4 g = 400 mg; 400 mg ÷ 200 mg per tablet = 2 tablets. Therefore, the nurse instructs the client to take 2 tablets per dose.
A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he could have prevented this condition. What should the nurse tell the client?
- A. See your physician for an early diagnosis and treatment of a sore throat.'
- B. As long as you do not have a fever, it is sufficient to gargle daily with an antibacterial mouthwash.'
- C. You may continue to utilize the previously prescribed antibiotics until they are gone.'
- D. Unscented bar soap may be used in showers.'
Correct Answer: A
Rationale: Early diagnosis and treatment of streptococcal infections prevent complications like glomerulonephritis. Mouthwash, leftover antibiotics, or soap use are not preventive measures.
A client with a history of chronic kidney disease is prescribed epoetin alfa (Epogen). The nurse should monitor the client for which of the following adverse effects? Select all that apply.
- A. Hypertension.
- B. Thrombosis.
- C. Hypokalemia.
- D. Hyperglycemia.
- E. Headache.
Correct Answer: A, B, E
Rationale: Epoetin alfa can cause hypertension, thrombosis, and headache due to increased red blood cell production.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.