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hemolytic reaction

Chest pain, nausea, having difficulty breathing, and chills. Later come symptoms of shock and loss of consciousness. This type of reaction occurs within minutes of starting the infusion.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select all that apply. Correct 1 Clients have a right to refuse treatment. Correct 2 Nurses are required to answer clients truthfully. Correct 3 The health care provider should have been notified. Incorrect 4 The client had insufficient knowledge to make such a decision. Incorrect 5 Legally prescribed medications are administered despite a client's objections.

Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. Client's questions must always be answered truthfully. The health care provider should be notified when a client refuses an intervention so that an alternate treatment plan can be formulated. This is done after the nurse explores the client's reasons for refusal. The client had a discussion with the nurse that indicated that the client had sufficient information to make the decision to refuse the medication. The client has a right to refuse treatment; this right takes precedence over the health care provider's prescription.

A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the health care provider to prescribe? 1 Norgestrel 2 Aminophylline Correct3 Dexamethasone Incorrect4 Magnesium sulfate

Dexamethasone is a glucocorticoid that stimulates the production of fetal lung surfactants, which are needed for fetal lung maturity; administration is started 48 hours before the expected birth.

A client with supraventricular tachycardia (SVT) is being treated with diltiazem hydrochloride (Cardizem). What assessment indicates to the nurse that the diltiazem hydrochloride is effective? 1) Blood pressure of 90/60 mm Hg 2) Heart rate of 110 beats per minute 3) No longer complaining of heart palpations 4) Increased urine output

Diltiazem hydrochloride's purpose is to slow the heart rate down. SVT has a heart rate of 150 to 250 beats per minute. A heart rate of 110 indicates that the diltiazem hydrochloride is having the desired effect. Hypotension is a side effect of diltiazem hydrochloride, not a desired effect. Heart palpations are experienced by some with various dysrhythmias. A decreased sensation of heart palpations is a positive finding but is not present in all clients. Increased urine output may occur over a period of time because of the increased ventricular filling time, but would not occur until after the heart rate had stabilized.

A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1) "I will take the drug with food." 2) "I must swallow my medication whole and not crush or chew it." 3) "I will stop taking Metformin for 24 hours before and after having a test involving dye." 4) "I will notify my doctor if I develop muscular or abdominal discomfort."

Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, Metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.

Voluntary sphincter control develops between 18 and 24 months of age. Signs of Readiness for Toilet Training

Physical Readiness • Child can remove own clothing. • Child is willing to let go of a toy when asked. • Child is able to sit, squat, and walk well. • Child has been walking for 1 year. Psychological Readiness • Child notices if diaper is wet. • Child may indicate that diaper needs to be changed by pulling on diaper, squatting, or repeating a word or phrase. • Child communicates need to go to the bathroom or can get there by self. • Child wants to please parent by staying dry

An 85-year-old client with a history of congestive heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sim's position, receiving oxygen at 2 L/min via nasal cannula. Which action would the nurse do first? 1) Raise the client to high-Fowler position 2) Obtain the apical pulse and blood pressure 3) Call the primary health care provider immediately 4) Monitor the pulse oximeter to ascertain the oxygen level

Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary health care provider immediately would not be useful without having a full set of vital signs, which should include the oxygen saturation, which the health care provider would expect the nurse to provide.

The health care provider has prescribed intravenous (IV) normal saline at 200 mL/hr and furosemide (Lasix) 120 mg orally stat for an 85-year-old client with a history of congestive heart failure. The best response is: 1) Place the normal saline on an infusion pump to control the amount and give the furosemide. 2) Ask the health care provider why so much intravenous fluid is to be given to an elderly client, and give the furosemide as prescribed. 3) Decline to give the intravenous fluid saying it could cause circulatory overload, and give the furosemide as prescribed. 4) Question the choice of solution, the amount to be given, and the dose of furosemide that has been prescribed.

The choice of normal saline at 200 mL/hr should be questioned for using saline, which is inclined to retain fluid, and the amount, which would be too much for most elderly persons' cardiac status to tolerate. This client is in congestive heart failure as evidenced by crackles and dyspnea and pulmonary edema is occurring. The standard initial dose of furosemide is 20-80mg. Giving a higher dose needs to be questioned and the nurse can refuse to follow prescriptions that are outside of standards. Using an infusion pump to infuse solution assures the prescribed amount is infused but does not address that this is too much. Giving a medication without understanding normal range and information violates standards. In addition, elderly clients do not metabolize medication as efficiently as younger clients.

A client weighing 125 kilograms (275 pounds), is considered to be in septic shock when the mean arterial pressure is less than 65 mm Hg or the systolic blood pressure is less than 90 mm Hg after receiving how many liters of intravenous crystalloids? 1 0.5 L Incorrect2 1 L 3 2 L Correct4 5 L

This question requires the learner to apply the formula for defining septic shock to the scenario described. A septic client is considered to be in septic shock if the client remains hypotensive, as defined in the stem of the question, in spite of receiving 20-40 mL/kg of crystalloids, making 5 L the correct option.