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.

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Correct Answer is D

Explanation

A. Nausea. Epinephrine is not primarily used to treat nausea. It is a sympathomimetic medication that works by stimulating alpha and beta receptors, mainly to counteract severe allergic reactions, including respiratory distress and hypotension. Nausea is not a primary indication for its use.
B. Hand tremors. Epinephrine can cause hand tremors as a side effect due to its stimulant effects on the nervous system. However, it is not used to treat tremors, and the presence of tremors after administration is a common physiological response rather than a therapeutic effect.
C. Hyperglycemia. Epinephrine can increase blood glucose levels by stimulating glycogenolysis and inhibiting insulin secretion. However, it is not used for treating hyperglycemia, and its effects on glucose metabolism are incidental rather than a primary therapeutic action.
D. Shortness of breath. Epinephrine is commonly used to treat anaphylaxis, which can cause airway swelling and bronchospasm leading to shortness of breath. By stimulating beta-2 receptors, epinephrine relaxes bronchial smooth muscles, improving airflow and reducing respiratory distress.

A. Encourage the client to use the overbed trapeze. B. Keep a loose, absorbent dressing over the client's surgical site. C. Maintain abduction of the client's residual limb with a pillow. D. Caution the client to avoid a prone position while in bed.

Correct Answer is A

Explanation

A. Encourage the client to use the overbed trapeze. Using an overbed trapeze helps the client build upper body strength, which is essential for mobility and independence following an amputation. Strengthening the arms and shoulders facilitates bed mobility, transfers, and eventual prosthetic use.
B. Keep a loose, absorbent dressing over the client's surgical site. The surgical site should be covered with a secure, sterile dressing to promote healing and prevent infection. Loose dressings can shift, increasing the risk of contamination and delayed wound healing.
C. Maintain abduction of the client's residual limb with a pillow. Prolonged abduction is not recommended, as it can lead to hip contractures. The limb should be kept in a neutral or slightly extended position to maintain proper alignment and prevent muscle shortening that could interfere with prosthetic use.
D. Caution the client to avoid a prone position while in bed. Prone positioning is actually encouraged intermittently to help stretch the hip flexors and prevent contractures. Avoiding this position may increase the risk of hip flexion contractures, making prosthetic fitting and ambulation more difficult.

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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 reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

Correct Answer is D

Explanation

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

Correct Answer is A

Explanation

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Exhibits The client is at risk of developing dropdownanddropdown

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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.