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.

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Correct Answer is D

Explanation

Choice A reason: Nausea and headache are common side effects of many medications, including linezolid, but they are not the most critical findings that need immediate reporting to the healthcare provider.

Choice B reason: Increased fatigue is a concerning symptom but may be related to the underlying infection or other factors. It is important to monitor but is not the most urgent finding in this context.

Choice C reason: Yellow-tinged sputum may indicate an ongoing infection, but it is not uncommon in cases of pneumonia. It should be monitored but does not require immediate reporting unless there are other concerning symptoms.

Choice D reason: Watery diarrhea is the most important finding to report because linezolid can cause Clostridioides difficile-associated diarrhea (CDAD), a potentially serious condition. Early detection and treatment are crucial to prevent complications.

A. Report the client's jaw pain to the healthcare provider. B. Advise the client to gargle with warm salt water twice daily. C. Determine how the client is administering the medication. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is A

Explanation

Choice A reason: Reporting the client's jaw pain to the healthcare provider is essential because jaw pain can be a symptom of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate therapy.

Choice B reason: Advising the client to gargle with warm salt water may provide temporary relief, but it does not address the underlying issue of potential osteonecrosis.

Choice C reason: Determining how the client is administering the medication is important for proper use but does not address the immediate concern of jaw pain.

Choice D reason: Confirming that this is a common symptom of osteoporosis is incorrect. Jaw pain is not a common symptom of osteoporosis and requires further evaluation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is D

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

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?

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

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?

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

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 mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?