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 ["C","E"]

Explanation

Preterm pre-labor rupture of membranes (PROM) is the spontaneous rupture of the amniotic sac before the onset of labor in a pregnancy less than 37 weeks gestation. It can lead to

infection, cord prolapse, placental abruption, and preterm delivery. The client has risk factors for PROM such as a history of preterm birth and a current infection indicated by fever.

Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. The client has signs of sepsis such as fever, tachycardia, and possible organ dysfunction. The client may have a urinary tract infection, a common cause of sepsis in pregnancy, or an intrauterine infection due to PROM or other factors.

Preeclampsia is not a likely complication for this client because she does not have high blood pressure or proteinuria, which are the defining features of preeclampsia. Seizures are not a likely complication for this client because she does not have epilepsy or eclampsia, which are the leading causes of seizures in pregnancy. Placenta previa is not a likely complication for this client because she does not have painless vaginal bleeding, which is the hallmark symptom of placenta previa.

A. “Use a nebulizer to administer a bronchodilator following airway clearance therapy.” B. “Administer pancreatic enzymes on an empty stomach.” C. “Perform chest percussion and postural drainage at least twice daily.” D. “Restrict intake of foods that contain gluten.”

Correct Answer is C

Explanation

This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.

Choice A is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.

Choice B is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach.

Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.

Choice D is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease.

Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten.

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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 has been admitted to the antepartum unit Exhibits The client is at risk for developing which of the following 2 complications? Select 2 complications the client is at risk of developing.

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

Explanation

A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

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 has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings is an indication that the medication has been effective

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

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.