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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.

Choice B rationale:

While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.

Choice C rationale:

Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.

Choice D rationale:

Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.

A. Unequal chest expansion. B. Atrophied neck and trapezius muscle. C. Increased tactile fremitus. D. An anterior-to-posterior chest diameter ratio of 1:1.

Correct Answer is A

Explanation

Choice A rationale:

Unequal chest expansion is the correct choice. In a patient with chronic obstructive pulmonary disease (COPD), the airways are often narrowed and obstructed, leading to difficulty in moving air in and out of the lungs. This can result in unequal chest expansion during breathing, where one side of the chest expands less than the other. This finding is commonly observed in patients with COPD due to the imbalance in lung function between different areas of the lungs.

Choice B rationale:

Atrophied neck and trapezius muscle is not a typical finding in COPD. Muscle atrophy can occur in conditions of prolonged disuse or immobility, but it is not a characteristic manifestation of COPD itself.

Choice C rationale:

Increased tactile fremitus refers to increased vibrations felt on the chest wall during speech. This finding is more commonly associated with conditions that cause lung consolidation, such as pneumonia. In COPD, there is often air trapping and hyperinflation of the lungs, which would not lead to increased tactile fremitus.

Choice D rationale:

An anterior-to-posterior chest diameter ratio of 1:1 is not a typical finding in a healthy individual, let alone in a patient with COPD. In COPD, there is often an increase in the anterior-to-posterior chest diameter ratio, giving the chest a barrel-like appearance. This is due to the trapped air and hyperinflation of the lungs, which is characteristic of the disease.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A Medical-Surgical nurse is performing an assessment on a client with a history of chronic obstructive pulmonary disease. Which of the following findings will the nurse most likely observe?

Correct Answer is A

Explanation

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

A patient has difficulty in breathing. The nurse provides oxygen therapy to the patient, after which the patient feels better. Which principle is involved in this situation?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

A nurse on a Medical-Surgical unit is caring for a client who has a suspected malignant lesion. Which of the following findings should the nurse expect when assessing the lesion? (Select all that apply.).

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 caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?