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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This client is relatively stable and the care required is within the scope of practice for a practical nurse (PN). Postoperative care for a laparoscopic cholecystectomy typically involves monitoring vital signs, pain management, and encouraging early ambulation, which the PN can perform with supervision.

Choice B reason: The older client with a colostomy for colon cancer may require more complex care and education about stoma management, which might be better suited for the RN.

Choice C reason: An older adult scheduled for foot amputation due to diabetes complications may have complex needs related to diabetes management and preoperative care, which require the RN's expertise.

Choice D reason: An adult with alcoholism, cirrhosis, and hepatic encephalopathy requires close monitoring for changes in mental status and liver function, which is more appropriate for the RN to manage.

A. Evaluate the UAP for signs of improvement. B. Discuss the issue privately with the UAP. C. Note date and time of the behavior. D. Plan for scheduled break times.

Correct Answer is C,B,D,A

Explanation

The correct order is:

Note date and time of the behavior.
Discuss the issue privately with the UAP.
Plan for scheduled break times.
Evaluate the UAP for signs of improvement.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is A

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is C,B,D,A

Explanation

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? 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 assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

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?

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

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?