The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above.

Start an IV bolus of lactated Ringer's solution.

Document the blood product transfusion in the client's medical record.

Discard the blood bag in the client's trash can after the transfusion.

Assist with obtaining the first unit of packed RBCs from the blood bank

Monitor the client for the first 15 min of the transfusion.

Answer and Explanation

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

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","D","E","G"]

Explanation

A. "Your baby will require Apgar scoring every 10 minutes after birth." Apgar scores are assessed at 1 and 5 minutes after birth. Additional assessments are only performed if there are concerns about the newborn’s condition, not at 10-minute intervals.
B. "Your baby's decelerations on the monitor could be caused by your positioning." Late decelerations were noted at 1530, which may indicate uteroplacental insufficiency. Maternal positioning can contribute to decelerations by compressing the umbilical cord or reducing placental perfusion. Repositioning, oxygen administration, and IV fluid boluses may help improve fetal oxygenation.
C. "You should receive betamethasone prior to delivery." Betamethasone is used to enhance fetal lung maturity in preterm labor before 34 weeks of gestation. Since this client is at 37 weeks, betamethasone is not needed.
D. "You will begin pushing when you have dilated more." The client is currently at 9 cm dilation, which is the transition phase of labor. Pushing should not begin until full cervical dilation at 10 cm to prevent cervical trauma and ensure effective labor progression.
E. “I will be monitoring your temperature closely." The client has ruptured membranes, which increases the risk of infection (chorioamnionitis). Frequent temperature monitoring is essential to detect early signs of infection.
F. "During this stage of your labor, you're not allowed to receive pain medication." Pain management options are available at all stages of labor. IV opioids may be avoided close to delivery to prevent neonatal respiratory depression, but epidural anesthesia can still be maintained.
G. "You can have some ice chips, if you would like." Clear fluids and ice chips are generally allowed during labor to help maintain hydration unless there is a contraindication, such as the need for an emergent cesarean under general anesthesia.

A. Completely undress the toddler. B. Allow the toddler to handle the equipment. C. Thoroughly explain each procedure to the toddler. D. Start the examination with routine immunizations.

Correct Answer is B

Explanation

A. Completely undress the toddler. Toddlers may feel vulnerable when fully undressed. It is best to remove clothing gradually, assessing one area at a time, to promote comfort and reduce anxiety.
B. Allow the toddler to handle the equipment. Letting the toddler touch and explore medical equipment, such as a stethoscope or otoscope, helps reduce fear and increases cooperation during the examination. This approach fosters a sense of control and familiarity.
C. Thoroughly explain each procedure to the toddler. Toddlers have limited understanding and attention spans. Simple, short explanations and distraction techniques are more effective in easing anxiety than detailed explanations.
D. Start the examination with routine immunizations. Painful procedures, such as vaccinations, should be saved for the end of the visit to prevent distress and resistance that could interfere with the rest of the examination.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client to the labor and delivery unit. Exhibits A nurse is reinforcing teaching to the client about the labor process. Select the 4 statements the nurse should make.

Correct Answer is ["B","D","E","G"]

Explanation

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for énalapril. Which of the following instructions should the nurse give the client?

A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client. Exhibits For each data collection finding, dick to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.