A nurse is caring for a client in a medical-surgical unit

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition:

Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

Weight (B): Monitor weight to assess for fluid retention and overload.
Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not an escharotomy.

B. "Large incisions will be made in the eschar to improve circulation." An escharotomy involves making large incisions through the eschar (the tough, leathery scab or crust that forms over a severely burned area) to relieve pressure and improve blood flow to the affected area. This procedure is often necessary to prevent complications such as compartment syndrome and to enhance circulation in burn patients.

C. "The procedure involves placing the client into a shower and removing the dead tissue.": This describes debridement, not an escharotomy.

D. "Dead tissue will be non-surgically removed.": Non-surgical removal of dead tissue is debridement, not an escharotomy, which is a surgical procedure.

A. Exposure to radiation B. Family history C. Another type of cancer D. Genetic mutation

Correct Answer is A

Explanation

A. Exposure to radiation - Exposure to high levels of radiation is a known risk factor for developing CML. Historical data, such as from atomic bomb survivors, show a higher incidence of leukemia, including CML, among those exposed to radiation.

B. Family history - CML is generally not associated with a significant familial risk. It is more commonly linked to acquired genetic mutations rather than inherited predispositions.

C. Another type of cancer - Having another type of cancer does not directly increase the risk of developing CML. However, treatments for other cancers, like radiation therapy, might increase risk.

D. Genetic mutation - The development of CML is associated with a specific acquired genetic mutation known as the Philadelphia chromosome (translocation between chromosomes 9 and 22), rather than inherited genetic mutations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Correct Answer is B

Explanation

A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the client's condition?(Select All that Apply.)

A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify which of the following persons is qualified?

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage? [Select All that Apply)