A 38-year-old client who is a Jehovah's Witness is involved in a major motor vehicle accident. The client was brought to the emergency department and was found to have lost too much blood, thus requiring a blood transfusion. The client is able to respond to questions appropriately. Which action should the nurse take in this situation?

Only fresh frozen plasma should be transfused to the client.

An immediate blood transfusion should be started due to the client's condition.

The client should be asked to decide about the blood transfusion.

The client's family should be notified immediately of the situation.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.

Choice B rationale:

Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.

Choice C rationale:

Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.

Choice D rationale:

Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.

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Correct Answer is B

Explanation

Choice B rationale:

The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.

Choice A rationale:

Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.

Choice C rationale:

Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.

Choice D rationale:

Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.

A. "I will wear synthetic clothing and woolen socks when using my oxygen.” B. "I will make sure my visitors smoke outside.” C. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter.” D. "I should call my doctor if I find it harder to concentrate.”

Correct Answer is A

Explanation

Choice A rationale:

This statement indicates a need for further teaching. Synthetic clothing and woolen socks can generate static electricity, which poses a risk around oxygen due to its flammable nature. The client should be advised to wear cotton clothing and avoid synthetic fabrics to prevent static-related accidents.

Choice B rationale:

This statement is correct. Oxygen supports combustion, so ensuring visitors don't smoke near the client is crucial. However, it does not indicate a need for further teaching.

Choice C rationale:

This statement is incorrect. The client cannot determine the oxygen flow rate by visual inspection of the flowmeter. The flow rate should be set based on the healthcare provider's instructions, and this information should have been covered in the teaching.

Choice D rationale:

This statement indicates the client understands the potential cognitive effects of oxygen therapy and when to seek medical assistance. It does not necessarily indicate a need for further teaching.

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Naxlex Comprehensive Predictor Exams

A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Correct Answer is B

Explanation

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct Answer is A

Explanation

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?

A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A Cardiovascular nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

A nurse is admitting a client who has measles and a persistent cough. Which of the following actions is a priority for the nurse to take?