The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Stay with the client for the first 15 min of the transfusion.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

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

Obtain the first unit of packed RBCs from the blood bank.

Start an IV bolus of lactated Ringer's solution.

Answer and Explanation

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

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

Nursing Test Bank

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Correct Answer is A

Explanation

The correct answer is choicea. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia.The fetus relies on maternal glucose for energy, and a significant drop in maternal glucose levels can affect the fetal heart rate.

Choice B rationale:

Maternal fever is typically associated with fetal tachycardia rather than bradycardia.An elevated maternal temperature can increase the fetal heart rate as the fetus attempts to regulate its own temperature.

Choice C rationale:

Chorioamnionitis, an infection of the amniotic fluid and membranes, is also more commonly associated with fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Fetal anemia can cause fetal tachycardia as the fetus compensates for the reduced oxygen-carrying capacity of the blood.Bradycardia is not a typical response to fetal anemia.

A. Vaginal culture. B. Obtain provider prescription for antibiotics. C. Urine culture. D. Ibuprofen 600 mg every 6 hr for mild to moderate pain. E. Obtain a provider prescription for phenazopyridine.

Correct Answer is ["C","E"]

Explanation

A urine culture is indicated for the client who has lower back pain and pinkish vaginal discharge, as these symptoms may suggest a urinary tract infection (UTI). A urine culture can identify the causative organism and guide the appropriate antibiotic therapy.

Phenazopyridine is a urinary analgesic that can relieve pain, burning, and urgency associated with a UTI. However, it requires a provider prescription and should not be used for more than two days.

A vaginal culture is not necessary for this client, as the vaginal discharge is likely due to the cervical changes during labor. A vaginal culture may be indicated for clients who have signs of vaginitis, such as itching, odor, or abnormal color of the discharge.

Obtaining a provider prescription for antibiotics is premature for this client, as the urine culture results are not available yet. Antibiotics should be prescribed based on the sensitivity of the organism causing the UTI.

Ibuprofen 600 mg every 6 hr for mild to moderate pain is not appropriate for this client, as it may interfere with uterine contractions and prolong labor. Ibuprofen is also contraindicated in the third trimester of pregnancy due to the risk of premature closure of the ductus arteriosus in the fetus. The nurse should use nonpharmacological methods to relieve the client’s back pain, such as massage, heat, or position changes.

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The nurse reviews the entries in the medical record. Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions is a possible cause of fetal bradycardia.

Correct Answer is A

Explanation

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["C","E"]

Explanation

A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?

A nurse is caring for a school-age child who is 2 hr postoperative following cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.