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.

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

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

Start an IV bolus of lactated Ringers solution.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg 4

Answer and Explanation

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

Rationale:

• Stay with the client for the first 15 min of the transfusion: The first 15 minutes of a blood transfusion are critical for monitoring signs of a transfusion reaction, such as fever, chills, rash, or hypotension. Continuous observation allows the nurse to promptly intervene and prevent complications.

• Obtain the first unit of packed RBCs from the blood bank: Retrieving the blood from the blood bank ensures that the correct product is available for transfusion and meets safety protocols. Verification of type and crossmatch is essential before administration.

• Document the blood product transfusion in the client's medical record: Accurate documentation of the transfusion, including product type, volume, time, and client response, is required for legal, medical, and safety purposes. It ensures continuity of care and provides a record for any adverse events.

• Start an IV bolus of lactated Ringers solution: Routine IV bolus of lactated Ringer’s is not indicated unless the client has persistent hypotension requiring fluid resuscitation. Blood transfusion itself is the primary intervention to correct anemia in this client.

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: While monitoring blood pressure is important, adjusting the transfusion rate specifically to maintain a numeric BP is not standard practice. The transfusion rate should follow protocol, usually starting slow for the first 15 minutes and then adjusted per tolerance, not solely based on BP.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","C","F"]

Explanation

Rationale:

A. "I will avoid all alcohol while taking this medication.": Alcohol can increase the risk of bleeding while a client is on anticoagulants by affecting platelet function and liver metabolism of the drug. Avoiding alcohol reduces the likelihood of complications such as gastrointestinal bleeding or excessive bruising, making this an appropriate and effective understanding of anticoagulant safety.

B. "I will ask my provider before taking any supplements.": Many herbal supplements and over-the-counter medications can interact with anticoagulants, either increasing or decreasing their effect. Consulting the provider ensures the client avoids dangerous interactions that could lead to bleeding or clotting complications.

C. "I will call my provider if I have blood in my urine.": Hematuria may indicate significant bleeding while on anticoagulant therapy. Promptly reporting this symptom allows early intervention and prevents serious complications such as anemia or renal damage, showing that the client understands the need to monitor for adverse effects.

D. "I will plan to eat a green salad every day.": While leafy green vegetables are healthy, they are high in vitamin K, which can interfere with certain anticoagulants like warfarin. Regular high intake without provider guidance could reduce the medication’s effectiveness, so this statement reflects a misunderstanding rather than effective teaching.

E. "I will stop taking the anticoagulant if I get a nosebleed.": Stopping anticoagulants without provider instruction can increase the risk of thromboembolism. Minor bleeding like a nosebleed should be reported, not managed by abruptly discontinuing the medication, so this reflects unsafe practice.

F. "I will be careful to not cut myself.": Minimizing trauma and preventing cuts or injuries is essential while on anticoagulants because even minor injuries can lead to significant bleeding. This shows the client understands the practical precautions needed to stay safe during therapy.

A. Reinforce orientation to time, place, and person B. Refute the client’s delusions using logic C. Establish eye contact when communicating with the client. D. Give the client one simple direction at a time. E. Allow the client to choose among a variety of activities each day.

Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. Reinforce orientation to time, place, and person: Regularly providing cues about the current time, location, and people helps reduce confusion and anxiety in clients with dementia. Orientation reinforcement supports cognitive functioning and promotes a sense of safety.

B. Refute the client’s delusions using logic: Arguing or attempting to correct delusions can increase agitation and distress. Therapeutic communication focuses on validation and redirection rather than confrontation, making this approach inappropriate for dementia care.

C. Establish eye contact when communicating with the client: Maintaining eye contact helps ensure the client’s attention and conveys engagement and respect. It enhances understanding and supports effective communication, especially when verbal comprehension may be impaired.

D. Give the client one simple direction at a time: Breaking tasks into single, clear instructions reduces cognitive overload and frustration. This approach increases the likelihood that the client can follow directions and participate successfully in activities of daily living.

E. Allow the client to choose among a variety of activities each day: While offering choices promotes autonomy, offering a large variety can be overwhelming for a client with dementia, leading to confusion, anxiety, and decision paralysis. The nurse should offer limited choices

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Body System	Findings
Neurological	Reports that dizziness and palpitations started 2 months ago. Alert and oriented to person, place, and time
Cardiovascular	Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally. Capillary refill time 5 seconds for all extremities. Reports no pain with palpation of thorax.
Respiratory	Fatigue and dyspnea with exertion started 1 week ago. Lungs clear to auscultation bilaterally
Vital Signs	Heart rate 105/min Respiratory rate 20/min Blood pressure 164/92 mm Hg Oxygen saturation 96% on room air

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

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

The nurse has reviewed the Provider Prescriptions at 1600. Exhibits The nurse is preparing the client for discharge. Select the 4 statements that indicate the teaching provided to the client about anticoagulant therapy was effective.

Correct Answer is ["A","B","C","F"]

Explanation

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?

The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results. Exhibits Select the 3 prescriptions the nurse should prescribe.

A nurse is teaching a client who is at 38 weeks of gestation about a contraction stress test. Which of the following statements should the nurse include in the teaching?

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdown and then dropdown

A nurse is caring for an adolescent who has a brain tumor and is receiving hospice care. The nurse is providing counseling regarding the stages of grief, which of the following statements by the adolescent is an example of the bargaining stage?

A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. 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.