Module 1 EAQ

which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? a. stop the blood transfusion and infuse saline b. administer the prescribed antipyretic c. obtain a prescription for an antihistamine d. notify the blood bank about the symptoms

a. stop the blood transfusion and infuse saline

which blood type is preferred for administration of blood to a client who has type B negative blood? a. A positive b. B negative c. O negative d. AB positive

b. B negative

A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood IV tubing? a. Lactated ringer solution b. 5% dextrose and water c. 0.9% normal saline d. 0.45% normal saline

c. 0.9% normal saline

which clinical response will the nurse assess to determine kidney damage in a client who develops transfusion reaction? a. glycosuria b. blood in the urine c. decreased urinary output d. acute pain over the kidney

c. decreased urinary output

which strategy would the nurse determine is the best method for teaching a 4 y/o about deep breathing before surgery? a. providing a pamphlet with pictures b. having the child blow a cotton ball across the table c. make up a game that involves using the incentive spirometer d. showing videotape of children doing deep breathing exercise

c. make up a game that involves using the incentive spirometer

which action by the nurse is best when a client who has a hemoglobin of 6g/dL (60 g/L) is refusing blood because of religious reasons? a. ask the client's family to intervene with the decision b. remind the client that death is a possibility without transfusion c. notify the health care provider of the client's refusal of blood products d. explain that the benefits of blood transfusion may outweigh religious concerns

c. notify the health care provider of the client's refusal of blood products

which action would the nurse take when a client refuses to take deep breaths and cough, saying "It's too painful" after an abdominal cholecystectomy? a. give pain medication as regularly as possible b. obtain a prescription to increase the client's pain medication c. schedule coughing and deep-breathing exercises after analgesic has taken effect d. substitute incentive spirometry for coughing and deep breathing

c. schedule coughing and deep-breathing exercises after analgesic has taken effect

which client receiving a blood transfusion who develops an adverse reaction would require immediate nursing intervention? a. itching b. flushing c. pruritus d. wheezing

d. wheezing

In which order would the nurse complete these steps when administering a blood transfusion? 1. ascertain that iv catheter size is 18 or 20 gauge 2. check pcp's rx 3. change main line solution to normal saline 4. check client identification before hanging unit of blood 5. obtain VS and hx of transfusions

-check pcp's rx -obtain VS and hx of transfusions -ascertain that iv -catheter size is 18 or 20 gauge -change main line solution to normal saline -check client identification before hanging unit of blood

Which technique would the nurse use to maintain surgical asepsis? a. change the sterile field after water is spilled on it b. put on sterile gloves before opening a container of sterile saline c. place a sterile dressing no more than half an inch from the edge of the sterile field d. clean the surgical area with a circular motion, moving from the outer edge toward the center

a. change the sterile field after water is spilled on it

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? a. instruct the client to splint the wound with a pillow when coughing b. place the client in the supine position and inspect the site of the incision c. assess the intensity of pain and administer the prescribed analgesic d. notify the HCP immediately and then check for wound dehiscence

a. instruct the client to splint the wound with a pillow when coughing

which action will the nurse take during administration of blood products to ensure the client's safety? a. stay with the client during the first 15 mins of infusion b. flush packed red blood cells with 5% dextrose and 0.45% normal saline c. remove the intravenous catheter if a blood transfusion reaction occurs d. administer the red blood cells through a percutaneously inserted central catheter line with a 20 gauge needle

a. stay with the client during the first 15 mins of infusion

which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion? a. stop the transfusion b. obtain vitals c. notify the HCP d. maintain the flow with normal saline

a. stop the transfusion

which action is the nurse's priority when the nurse notices the client receiving a blood transfusion is having an acute hemolytic reaction? a. stop the transfusion immediately b. report to the PCP c. recheck identifying tags and numbers on the client d. maintain a patent IV line with saline solution

a. stop the transfusion immediately

Which finding by the nurse is the best indicator that measures to prevent postoperative atelectasis after abdominal surgery have been effective? a. vesicular breath sounds heard over the lungs b. client reports no incisional pain with coughing c. clients oral temp is 98.2 (36.8) d. client uses incentive spirometer q 2 hours

a. vesicular breath sounds heard over the lungs

Which technique would the nurse use in attempting to glove the second hand when donning sterile gloves? a. grasp the finger portion of the second glove and lift; then insert remaining hand into glove b. insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove c. using your gloved hand, grasp the folded edge of the second glove with two fingers and place glove on non dominant hand d. don glove on nondominant hand first, then hold the glove away from body and below waist to slide glove on

b. insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove

which would the nurse include when teaching a client about the use of an incentive spirometer? a. inhale completely and exhale in short rapid breaths b. inhale deeply through the spirometer, hold it as long as possible, and slowly exhale c. exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale d. exhale halfway, then inhale a rapid, small breath; repeat several times

c. exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale

which action would the nurse take next after the nurse immediately stops the infusion of a client demonstrating signs and symptoms of a transfusion reaction? a. obtain blood pressure and pulse b. send a urine specimen to the lab c. hang a bag of normal saline with new tubing d. monitor the intake and output every 15 mins

c. hang a bag of normal saline with new tubing

A family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. Which action would the nurse take to handle the situation? a. wait for the court's order to give blood to the client b. proceed with the transfusion to save the client's life c. inform the primary health care provider and not give blood to the client d. explain to the family member that the client need this transfusion

c. inform the primary health care provider and not give blood to the client

A client receiving a blood transfusion reports itching and difficulty breathing. Upon assessment the nurse notes an increased heart rate and low blood pressure. Which type of shock would the nurse suspect the client is experiencing? a. septic shock b. cardiogenic shock c. neurogenic shock d. anaphylactic shock

d. anaphylactic shock

which action would the nurse take to prevent venous thrombus formation after abdominal surgery? a. keep the client in a gatch bed to elevate the knees b. have the client dangle the legs off the side of the bed c. help the client use incentive spirometry every hour d. encourage the client to ambulate multiple times daily

d. encourage the client to ambulate multiple times daily

which nursing action is important when transfusing packed red blood cells to a client with a diagnosis of anemia? a. assessing the client for fluid overload b. monitoring the client's response, particularly within the first 10 minutes c. assuring that the transfusion flows at a consistent rate during the procedure d. having the client tested for human immunodeficiency virus before administration

b. monitoring the client's response, particularly within the first 10 minutes

Which action should the nurse take to maintain sterility when performing a dressing change? a. put the unopened sterile glove package carefully on the side of the sterile field b. remove the sterile drape from its package by lifting up the corners c. don sterile gloves before opening the package containing the field drape d. pour irrigation liquid from a heigh of at least 3 inches (2.5 cm) above the sterile container

b. remove the sterile drape from its package by lifting up the corners liquids would be poured 4 to 6 inches (10-15 cm) above

The nurse is caring for a client on bed rest. Which nursing intervention would prevent a pulmonary embolus? a. limit the client's fluid intake b. teach the client how to exercise the legs c. encourage use of incentive spirometer d. maintain elevation of the knees at an angle

b. teach the client how to exercise the legs

The spouse of a comatose client refuses to allow transfusions of whole blood because they are Jehovah's witnesses. The client does not have a durable power of attorney for health care (DPHAC). Which action by the nurse is correct? a. institute the prescribed blood transfusion because the client's survival depends on volume replacement b. clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion c. phone the primary health care provider for an administrative prescription to give the transfusion under these circumstances d. give the spouse a treatment refusal form to sign and notify the PCP so legal action can be considered

d. give the spouse a treatment refusal form to sign and notify the PCP so legal action can be considered