Set 5

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish brown urine in the clients urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic A hemolytic reaction occurs when the clients blood is incompatible with the donors blood. Chills, lower back pain, hypertension, and tachycardia are indications of hemolytic transfusion reaction.

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficit? A. Obtain the apical and radial rate simultaneously B. Check the blood pressure in the left and right arms C.Compare the pulse strength in the upper extremities D.Palpate the pulses in the lower extremities

A.Obtain the apical and radial rates simultaneously To assess for a pulse deficit, the nurse and a second person assess the clients radial and apical pulse is simultaneously and then compare both rates. To calculate the pulse deficit, the nurse should subtract the difference between the apical and radial pulse rates

A nurse is admitting a client who has tuberculosis. Addition to standard precautions, which of the following transmission based precautions should the nurse add to the clients plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne Tuberculosis requires airborne precautions which are protocols to prevent the spread of infection to via very small droplets

A nurse is caring for a client who is receiving intermittent internal feedings through an NG tube. The specific gravity of the clients urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request eight lower fat formula C. Provide more water with feedings D. Instill a lactose-free formula

C. Provide more water with feedings The elevation in the client specific gravity indicates dehydration. The nurse should provide more fluid either by adding free water to feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein.

A nurse is caring for a client who was hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A. Perform tracheostomy care using medical asepsis B. Allow enough slack under the tracheostomy ties to insert three fingers C. Soak the inner cannula of the tracheostomy tube in normal saline D. Cut a sterile gauze pad to place between the neck and the tracheostomy tube

C. So the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions

A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse

D. Bounding pulse Rebounding pulse is an expected finding a fluid volume excess

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders

D. Plasma volume expanders Dextran and albumin or plasma volume expanders that help correct hypovolemia in emergency situations, such as hemorrhage or burns.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake 225 kcal per kilogram of body weight B. Provide an intake of 500 mg per day of vitamin E C. Limit fluid intake to 20 mL per kilogram of body weight per day D. Provide a protein intake of 1.5 g per kilogram of body weight per day

D. Provide a protein intake of 1.5 g per kilogram of body weight per day A protein intake of 1 to 1.5 g per kilogram of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Ericksons developmental task for her age group? A. I am comfortable with my decision to choose a lifelong partner B. I think I have done a good job with my children since they are all independent now C. As I look back over my life, I can see that I have achieved most of the goals I set for myself D. I love my work so much that it is difficult to think about retirement

B. I think I have done a good job with my children since they are all independent now According to Ericsson, the developmental task for middle adult is generativity versus stagnation. Middle adults help shape future generations to community involvement, parenting, mentoring, and teaching. This statement about helping her children achieve independence and the kids that the client has accomplished this developmental task

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue to teaching, but check afterward with the surgeon about informed consent. B. Stop the teaching and check with the surgeon about informed consent. C. Stop the teaching and ask the client to sign an informed consent form. D. Continue the teaching and check the clients medical records afterward for a signed consent form.

B. Stop the teaching and check with the surgeon about informed consent. The client statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon.

A nurse is assessing a clients nutritional status. The nurse demonstrates the client is consuming 500 cal more per day and his energy level requires if his dietary habits do not change, how long will it take the client to gain 4.5 kg or 10 pounds? A. 10 months B. Five months C. Five weeks D. 10 weeks

D. 10 weeks Because 1 pound of body fat is equivalent to 3500 cal, consuming 500 extra calories each day for seven days would lead to a total of 3500 cal and a 1 pound game per week. at the rate of 1 pound per week, the client would gain 10 pounds in 10 weeks.

A nurse is evaluating a clients use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? A. The client place is a credit on each side when assuming a sitting position B. The client move the unaffected leg onto a step first when descending stairs C. The client places we on the axillae went walking D.The client has slightly flexed elbow is when ambulating with crutches

D. The client has slightly flexed elbows when ambulating with crutches The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae.