A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Observe the client for 1 hr after meals.

Obtain the client's vital signs every other day.

Weigh the client every 48 hr.

Allow the client to eat meals in their room.

Answer and Explanation

The Correct Answer is A

Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.

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Correct Answer is A

Explanation

A. Acute hemolytic:
Acute hemolytic transfusion reactions typically present with symptoms such as fever, chills, flank pain, hemoglobinuria (blood in the urine), and possibly hypotension. This occurs due to the rapid destruction of transfused red blood cells, often because of ABO incompatibility between the donor and recipient. The symptoms described in the scenario, including chest tightness, are not consistent with acute hemolytic reactions.

B. Allergic:
Allergic reactions to blood transfusions can manifest with symptoms such as itching, hives, flushing, and mild respiratory distress. While headache and low-back pain can occur in allergic reactions, the feeling of "tightness" in the chest is more indicative of another type of reaction.

C. Bacterial:
Bacterial contamination of blood products can lead to transfusion-related sepsis. Symptoms may include fever, chills, hypotension, and rapid onset of shock. However, the presence of headache and low-back pain, along with chest tightness, is not typically associated with bacterial contamination.

D. Febrile nonhemolytic:
Febrile nonhemolytic transfusion reactions are characterized by fever, chills, and rigors. While fever and chills are common symptoms, they do not typically cause chest tightness or low-back pain.

A. Request insertion of a tracheostomy tube. B. Suction the client's airway. C. Tighten the tubing connections. D. Look for a leak in the tube's cuff.

Correct Answer is B

Explanation

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.

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A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is A

Explanation

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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