Following a gunshot wound, an adult client has a hemoglobin level of 4 g/dL (40 g/L). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement?

Administer normal saline solution until Type AB negative is available.

Obtain additional consent for administration of Type A negative blood.

Recheck the client's hemoglobin, blood type, and Rh factor.

Transfuse Type A negative blood until Type AB negative is available.

Answer and Explanation

The Correct Answer is D

Choice A reason: Administering normal saline solution alone will not address the severe anemia caused by the low hemoglobin level.

Choice B reason: Obtaining additional consent is necessary, but it is not the immediate action required in this emergency situation.

Choice C reason: Rechecking the client's hemoglobin, blood type, and Rh factor is important, but the immediate priority is to address the severe anemia.

Choice D reason: Transfusing Type A negative blood is appropriate because it is compatible with AB negative blood and is necessary to treat the client's critical anemia.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A reason: Assessing skin turgor is important for hydration status but not specifically related to prasugrel.

Choice B reason: Observing the color of urine is important as it can indicate hematuria (blood in the urine), a potential adverse effect of prasugrel, which is an antiplatelet medication that increases the risk of bleeding.

Choice C reason: Checking for pedal edema is important for overall cardiovascular assessment but not specifically related to monitoring adverse effects of prasugrel.

Choice D reason: Measuring body temperature is important for detecting infection but not specifically related to prasugrel's adverse effects.

A. Observe the appearance of the client's urine. B. Measure the girth of the client's lower abdomen. C. Auscultate an area six inches below the umbilicus. D. Palpate the area above the pubic symphysis.

Correct Answer is D

Explanation

Choice A reason: Observing the appearance of urine can provide information but is not the most direct assessment for urinary retention.

Choice B reason: Measuring the girth of the lower abdomen is not a specific assessment for urinary retention.

Choice C reason: Auscultation is not a reliable method for assessing urinary retention.

Choice D reason: Palpating above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is B

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?