A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?

Headache

Dyspnea

Hyperthermia

Urticaria

Answer and Explanation

The Correct Answer is B

A.   Headache can be a common side effect of blood transfusion but is not typically considered an urgent or life-threatening complication requiring immediate reporting.
B.   Dyspnea (difficulty breathing) can indicate a serious transfusion reaction such as transfusion- related acute lung injury (TRALI) or circulatory overload and should be reported immediately to the provider for further evaluation and intervention.
C.   Hyperthermia (elevated body temperature) may indicate a febrile reaction to the transfusion but is not as immediately life-threatening as dyspnea.
D.   Urticaria (hives) is a common allergic reaction to blood transfusion but is not typically considered as urgent or life-threatening as dyspnea.

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Correct Answer is C

Explanation

A. The stoma bleeds lightly when touched: Light bleeding is common postoperatively and may not be concerning unless it's excessive or persistent.
B. The stoma is draining a small amount of liquid stool: This is a normal finding following colostomy placement and is expected in the early postoperative period.
C. The stoma appears dark in color: This may indicate compromised blood supply to the stoma and requires immediate evaluation by the provider.
D. The stoma protrudes slightly from the abdomen: This is a normal finding post-colostomy and does not typically require immediate intervention.

A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. B. Unlock and remove the inner cannula. C. Scrub the inside and outside of the inner cannula with a small brush. D. Wipe the inside of the inner cannula with a folded pipe cleaner. E. Cleanse the stoma site with 0.9% sodium chloride solution.

Correct Answer is A,B,C,D,E

Explanation

Pouring 0.9% sodium chloride solution into the sterile basin provides the solution necessary for cleaning the inner cannula.

Unlocking and removing the inner cannula is the first step in the process of tracheostomy care.

Scrubbing the inside and outside of the inner cannula with a small brush helps remove secretions and debris.

Wiping the inside of the inner cannula with a folded pipe cleaner further cleans the inner surfaces.

Cleansing the stoma site with 0.9% sodium chloride solution completes the tracheostomy care procedure.

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A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

48. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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