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Client Statement

Exhibits

The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.

I purchased a large magnifying glass.

I’m adding bananas to my oatmeal every morning.

Instead of being barefoot, I wear socks.

I moved my medicine bottles into the living room.

I switched to eating apples and oranges for a nighttime snack.

I placed a lamp on my bedside table.

I prepared a large batch of beans, so I have a fast meal every night.

I added a nonslip throw rug at my kitchen sink.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Choice A Reason:

The client states, “I purchased a large magnifying glass.” While this shows an attempt to address the issue of blurred vision, it does not fully address the safety concerns related to macular degeneration. The client should be encouraged to use additional visual aids, such as better lighting and possibly electronic magnifiers, to ensure they can see clearly and avoid accidents. Therefore, this statement indicates that the client needs further teaching.

Choice B Reason:

The client states, “I’m adding bananas to my oatmeal every morning.” This is a positive dietary change. Bananas are rich in potassium, which can help manage blood pressure, a crucial aspect for someone with hypertension. Additionally, adding fruit to breakfast can improve overall nutrition. Therefore, this statement indicates that the client understood the teaching.

Choice C Reason:

The client states, “Instead of being barefoot, I wear socks.” While wearing socks is better than being barefoot, it is not the safest option. Socks can still be slippery on certain surfaces, increasing the risk of falls. The client should be encouraged to wear non-slip shoes or slippers inside the house. Therefore, this statement indicates that the client needs further teaching.

Choice D Reason:

The client states, “I moved my medicine bottles into the living room.” While this might make the medications more accessible, it is not the safest practice. Medications should be stored in a cool, dry place, away from direct sunlight and moisture. Additionally, they should be kept in a location where they are easily visible and accessible but not in a high-traffic area where they could be knocked over. Therefore, this statement indicates that the client needs further teaching.

Choice E Reason:

The client states, “I switched to eating apples and oranges for a nighttime snack.” This is a positive dietary change. Apples and oranges are rich in vitamins and fiber, which are beneficial for overall health. This change also indicates an understanding of the need to incorporate more fruits into the diet. Therefore, this statement indicates that the client understood the teaching.

Choice F Reason:

The client states, “I placed a lamp on my bedside table.” This is a good practice as it ensures that the client has adequate lighting when getting in and out of bed, reducing the risk of falls. Therefore, this statement indicates that the client understood the teaching.

Choice G Reason:

The client states, “I prepared a large batch of beans, so I have a fast meal every night.” This is a positive change as it ensures that the client has a nutritious meal readily available, reducing the reliance on processed frozen meals. Beans are a good source of protein and fiber, which are important for overall health. Therefore, this statement indicates that the client understood the teaching.

Choice H Reason:

The client states, “I added a nonslip throw rug at my kitchen sink.” While the intention is good, throw rugs can still pose a tripping hazard, even if they are nonslip. It would be safer to use a mat that is securely fixed to the floor. Therefore, this statement indicates that the client needs further teaching.

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Correct Answer is A

Explanation

Choice A reason: Generalized Urticaria

Generalized urticaria, or widespread hives, is a common sign of an allergic transfusion reaction. This reaction occurs when the recipient’s immune system reacts to proteins in the donor blood. Symptoms can range from mild, such as itching and hives, to severe, including anaphylaxis. Immediate intervention typically involves stopping the transfusion and administering antihistamines.

Choice B reason: Distended Jugular Veins

Distended jugular veins are not indicative of an allergic transfusion reaction. This finding is more commonly associated with conditions such as congestive heart failure or fluid overload. In the context of a blood transfusion, it could suggest circulatory overload rather than an allergic reaction.

Choice C reason: Blood Pressure 184/92 mm Hg

An elevated blood pressure reading, such as 184/92 mm Hg, is not specific to an allergic transfusion reaction. While blood pressure changes can occur during a transfusion, they are not a hallmark of an allergic response. This finding could be related to other factors, such as anxiety or pre-existing hypertension.

Choice D reason: Bilateral Flank Pain

Bilateral flank pain is not a typical symptom of an allergic transfusion reaction. This symptom is more commonly associated with hemolytic transfusion reactions, where the recipient’s immune system attacks the donor red blood cells, leading to hemolysis and subsequent kidney pain.

Correct Answer is ["100"]

Explanation

Step 1: Identify the infusion rate in mL/hr.

The infusion rate is 100 mL/hr.
= 100 mL/hr.

Step 2: Determine the drop factor for microtubing.

Microtubing has a drop factor of 60 gtt/mL.
= 60 gtt/mL.

Step 3: Calculate the drip rate in gtt/min.

Drip rate (gtt/min) = (Infusion rate in mL/hr) × (Drop factor in gtt/mL) ÷ 60.
Drip rate (gtt/min) = 100 mL/hr × 60 gtt/mL ÷ 60.
= 100 gtt/min.

So, the nurse should set the manual IV infusion to deliver 100 gtt/min.

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Client Statement Exhibits The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Correct Answer is A

Explanation

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)

Correct Answer is ["100"]

Explanation

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Client Statement

Exhibits

The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.