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

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The nurse suspects that the client has developed
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based on
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.

Answer and Explanation

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

Rationale for correct choices:
• Transfusion-associated circulatory overload: Characterized by dyspnea, cough, crackles in the lungs, jugular vein distention, and hypertension due to fluid overload during transfusion. The client’s findings of shortness of breath, cough, crackles, and distended neck veins directly align with this condition.

• Lung sounds: The presence of new crackles bilaterally along with dyspnea indicates fluid overload affecting pulmonary circulation, consistent with TACO.

Rationale for incorrect choices:

• Acute intravascular hemolytic reaction: This reaction presents with flank pain, fever, chills, and hemoglobinuria due to incompatible blood. The client shows no evidence of hematuria, fever spike, or severe back pain.

• Anaphylactic reaction: Anaphylaxis occurs rapidly, with symptoms such as bronchospasm, hypotension, urticaria, and possible shock. The client does not have a rash, hives, or hypotension, which rules this out.

• Febrile nonhemolytic reaction: Typically presents with fever, chills, and headache caused by donor WBCs. The client’s temperature is stable and no chills are reported, so this does not match.

• Sepsis transfusion reaction: This occurs when contaminated blood is transfused, leading to fever, hypotension, and rigors. The client is not hypotensive or febrile, making this less likely.

• Temperature: A temperature rise would point to a febrile or septic transfusion reaction, but the client’s temperature remained stable.

• Urticaria: Urticaria would suggest an allergic or anaphylactic reaction, which was not observed.

• Hypotension: Hypotension is seen with hemolytic or septic reactions, but this client’s blood pressure is elevated, not decreased.

• Chills: Chills are typical of febrile or hemolytic reactions, but the client did not report them.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.

B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.

C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.

D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.

A. Change the secondary IV infusion set twice weekly. B. Change a continuously infusing IV bag after 48 hr. C. Change the primary IV infusion set every 96 hr. D. Change the extension tubing once per week.

Correct Answer is C

Explanation

A. Change the secondary IV infusion set twice weekly: Secondary IV sets, such as piggyback infusions, should generally be changed every 24 hours to reduce the risk of contamination and infection. Changing them twice weekly would not maintain proper asepsis.

B. Change a continuously infusing IV bag after 48 hr: Continuous IV bags should be replaced at least every 24 hours to prevent bacterial growth. Waiting 48 hours increases the risk of microbial contamination and bloodstream infections.

C. Change the primary IV infusion set every 96 hr: Changing the primary IV infusion set every 96 hours (4 days) aligns with standard infection-control guidelines. This interval helps maintain asepsis while minimizing the risk of IV-related infections.

D. Change the extension tubing once per week: Extension tubing connected to the IV line should be changed more frequently, typically every 72 to 96 hours, to prevent contamination. Once per week is too infrequent and increases infection risk.

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A nurse is caring for a male client on a medical-surgical unit. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The nurse suspects that the client has developed dropdownbased ondropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

Correct Answer is A

Explanation

A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?

Correct Answer is C

Explanation

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

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The nurse suspects that the client has developed
dropdown
based on
dropdown
.