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 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

A. "Why are you angry about taking insulin?" B. "Don't worry. Diabetes runs in my family as well." C. "I see that you are angry. Let's sit down and talk." D. "You should take insulin because it reduces the risk for complications."

Correct Answer is C

Explanation

A: Asking the client why they are angry may come across as confrontational and defensive, potentially escalating the situation. It does not promote open communication or therapeutic rapport.
B: Sharing personal information about diabetes running in the nurse's family is not relevant to the client's feelings or concerns and may not be helpful in addressing the client's anger.
C: Correct. Acknowledging the client's feelings of anger and offering to sit down and talk provides an opportunity for therapeutic communication. This response demonstrates empathy and a willingness to listen and address the client's concerns about insulin therapy.
D: While it is true that insulin therapy can help reduce the risk of complications in type 2 diabetes, this response may come across as dismissive of the client's feelings and concerns. It does not address the emotional aspect of the client's anger.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?

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?

Nurse is caring for a client following abdominal surgery. Exhibits Select the findings the nurse should report to the provider.

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?

A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?

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)?