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) Autonomy refers to the right of the client to make their own decisions about their care. In this scenario, the nurse respects the client's decision not to take the pill as it is, but does not stop there.
B) Beneficence is the principle of doing good and acting in the best interest of the client. By offering to break the pill, the nurse is actively seeking a solution to ensure the client receives the necessary medication, which is in the client's best interest.
C) Justice relates to fairness and the equal distribution of resources. While important, it is not the primary principle being demonstrated in this situation.
D) Nonmaleficence means to do no harm. Although breaking the pill could be seen as avoiding harm by preventing the client from choking, it is more about ensuring the client's treatment continues effectively, which aligns more closely with beneficence.

A. Allow the client to continue taking the medications as they did at home. B. Take the medications from the client and discard them. C. Compare the medications the provider has prescribed with the client's medications from home. D. Place the medications in the medication cart and administer them as the client takes them at home.

Correct Answer is C

Explanation

A: Allowing the client to continue taking medications as they did at home without verifying the prescriptions can be unsafe and is not within the scope of nursing practice.
B: Taking the medications from the client and discarding them is inappropriate. The nurse should not dispose of the client's medications without proper assessment and verification.
C: Correct. The nurse should compare the medications the provider has prescribed with the medications the client brought from home to ensure accuracy and safety. This is a crucial step during admission to prevent errors or omissions in the medication regimen.
D: Placing the medications in the medication cart and administering them without verification is unsafe and against best practices for medication administration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

Correct Answer is C

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 preparing to administer a topical medication to a client. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

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A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

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A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?