A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Vital Signs

0800:

Blood pressure 112/64 mm Hg

Heart rate 80/min

Respiratory rate 18/min

Temperature 37.1° C (98.8" F

Oxygen saturation 97% on room air

08151

Blood pressure 106/54 mm Hg Heart rate 100/min

Respiratory rate 22/min Temperature 37° C (98,6°F)

Oxygen saturation 95% on room air

Complete the following sentence by using the lists of options.
The client has manifestations of
an , as evidenced by the

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

A. A Provide privacy for the client B. B Expose hair of the body as a

Correct Answer is A

Explanation

A. Provide privacy for the client CORRECT
The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment
B. Expose hair of the body as an INCORRECT
To promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

A nurse in an emergency department is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse should first review the medications that may be causing the client's dropdown followed by dropdown

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

A nurse is taking notes of client information on a piece of paper while receiving a report. Which of the following actions should the nurse take to dispose of the paper?