Blood Transfusion
The nurse is observing newly hired nurse on the unit who is preparing to administer blood transfusion. Which of the following actions of the newly hired nurse requires intervention by the nurse
A. Inserts a large bore IV catheter in the client
B. Verifies blood compatibility and expiration date of blood w/ assistive personnel (UAP)
C. Administer 0.9% sodium chloride IV
D. Assess for history of blood transfusion reactions
B. Verifies blood compatibility and expiration date of blood w/ assistive personnel (UAP)
A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol (Proventil). Which of the following statements made by the client indicates an understanding of the teaching?
A. this medication can increase my blood sugar levels
B. this medication can decrease my immune response
C. I can have an increase in my heart rate while taking this medication
D. I can have mouth sores while taking this medication
C. I can have an increase in my heart rate while taking this medication
A nurse is providing palliative care for a client who-stage lung cancer and is dyspneic. Which of the following actions should the nurse take?
A. Administer haloperidol 0.5 mg sublingual.
B. Ask the client how he is feeling.
C. Place the client in the supine position.
D. Apply supplemental oxygen
D. Apply supplemental oxygen.
The nurse should apply supplemental oxygen as a palliative measure for a client who has end-stage lung cancer and is dyspneic. The oxygen will ease the client's breathing and provide comfort to the client.
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?
a. "Taking the medication between meals will help you avoid becoming constipated."
b. "Taking the medication with food increases the risk of esophagitis."
c. "Taking the medication between meals will help you absorb the medication more efficiently."
d. "The medication can cause nausea if taken with food."
c. "Taking the medication between meals will help you absorb the medication more efficiently."
The nurse provides discharge instructions to a patient who is neutropenic. Which patient statements indicate the need for additional teaching? Select all that apply.
1.
“My plants are being moved outside.”
2.
“I will avoid eating raspberries and blackberries.”
3.
“I will use a humidifier to moisten the air at night.”
4.
“I will wash all raw vegetables before eating them.”
5.
“My prescribed antibiotic can be stopped once I feel better.”
3. “I will use a humidifier to moisten the air at night.”
5.
“My prescribed antibiotic can be stopped once I feel better.”
A nurse should remain with a client during the first 15 minutes of a blood transfusion to: ch.40
A. verify the blood is being transfused
B. assess for an adverse reaction
C. explain the procedure to the client
D. obtain blood specimens
B. assess for an adverse reaction
A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?
A. there are portable oxygen delivery systems that you can take with you
B. when you go out, you can remove the oxygen and then reapply it when you get home
C. you probably will not be able to go out as much as you used to
D. home health services will come to you so you will not need to get out
A
Rationale: The nurse should inform the client that there
are portable oxygen systems that he can use to leave the
house. This should alleviate the client's anxiety.
A nurse is caring for a client who has cancer. The goal of palliative pain management is to increase which of the following? (Select all that apply).
Mental acuity
Physical mobility
Time spent at home
Quality of life
Bowel function
Physical mobility
Time spent at home
Quality of life
The nurse in a clinic receives a phone call from a client seeking information about his new prescription for erythropoietin (epogen). Which of the following should be reviewed with client?
A. The client needs an erythrocyte sedimentation rate (ESR) test weekly
B. The client should have his hemoglobin (Hgb) checked regularly
C. Oxygen saturation levels should be monitored
D. Folic acid production will increase
B. The client should have his hemoglobin (Hgb) checked regularly
Which is the priority teaching point for the nurse to include in the discharge instructions for the patient being discharged after treatment for sickle cell crisis?
1.Rapid weaning of pain medications
2.A diet high in protein
3.Adequate hydration
4.Restriction of activities
3.Adequate hydration
A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? Select all that apply.
a. Check vital signs before transfusion.
b. Insert an IV with a 19-gauge needle.
c. Prime the blood tubing with dextrose 5% in water.
d. Transfuse the blood product within 5 hours after removing it from refrigeration.
e. Check the expiration date of the blood product with a second nurse.
a. Check vital signs before transfusion.
b. Insert an IV with a 19-gauge needle.
e. Check the expiration date of the blood product with a second nurse.
A nurse is preparing to administer a new prescription prednisone (deltasone) to a client who has COPD. Which of the following should the nurse monitor for? (Select all)
A. monitor the client for hypokalemia
B. monitor the client for tachycardia
C. observe the client for fluid retention
D. monitor the client for nausea
E. advise the client to report black, tarry stools
A. monitor the client for hypokalemia
C. observe the client for fluid retention
E. advise the client to report black, tarry stools
hich of these does the nurse recognize as the goal of palliative surgery for the client with cancer?
A. Prolonging the client's survival time
B. Relief of symptoms or improved quality of life
C. Allowing other therapies to be more effective
D. Cure of the cancer"
B. Relief of symptoms or improved quality of life
A nurse is caring for a client who receives furosemide (Lasix) to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication?
a. potassium
b. albumin
c. cortisol
d. bicarbonate
a. potassium
Furosemide is a loop diuretic that promotes the excretion of potassium. The nurse should monitor the client's potassium level to watch for hypokalemia.
A patient complaining of mouth soreness had gastric bypass surgery 1 year ago. During the assessment, the nurse notes the patient's tongue is beefy, red, and smooth and the patient's skin appears yellowish. The nurse correlates these findings to a decreased value of which diagnostic test?
1.Vitamin B6 levels
2.Vitamin B12 levels
3.Platelet count
4.Iron levels
2.Vitamin B12 levels
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply.) ch.40
A. stop the transfusion
B. send the blood bag and IV tubing to the blood bank
C. maintain an IV infusion with 0.9% sodium chloride
D. elevate the client's feet
E. obtain blood cultures
A. stop the transfusion
B. send the blood bag and IV tubing to the blood bank
C. maintain an IV infusion with 0.9% sodium chloride
A nurse is instructing a client on the use of an IS. Which of the following statements made by the client indicates an understanding of the teaching?
A. i will place the adapter on my finger to read my blood oxygen sat levels
B. i will lie on my back with my knees bent
C. i will rest my hand over my abdomen to create resistance
D. i will take in a deep breath and hold it before exhaling
D. I will take in a deep breath and hold it before exhaling
Rationale: The nurse should inform the client that there
are portable oxygen systems that he can use to leave the
house. This should alleviate the client's anxiety.
A nurse is providing palliative care for a client who has bone cancer. The client reports chronic pain all over his body. Which of the following nonpharmacological comfort interventions should the nurse take?
A. Massage the client's extremities
B. Increase the client's room temperature
C. Obtain a prescription for physical therapy
D. Have a family member visit with client
A. Massage the client's extremities
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?
1. I will call my health care provider if my stools turn black
2. I will take a stool softener if I feel constipated occasionally
3. I should take the iron with orange juice about an hour before eating
4. I should increase my fluid and fiber intake while I am taking iron tablets.
1. I will call my health care provider if my stools turn black
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.
The nurse develops the nursing diagnosis "Risk for Bleeding related to lack of intrinsic factor" for the patient with which hematological disorder?
1.Iron deficiency anemia
2.Pernicious anemia
3.Folic acid deficiency anemia
4.Glucose-6-phosphate dehydrogenase (G6PD) deficiency
2.Pernicious anemia
A nurse is completing preoperative teaching with a client who will undergo an elective surgical procedure that will include a blood transfusion. Which of the following statements by the nurse should be included int he teaching? ch.40
A. "You should make an appointment o donate blood 8 weeks prior to the surgery."
B. "If you need an autologous transfusion, the blood your brother donates can be used."
C. "We will have you come in to donate your blood the day before surgery."
D. "You will receive the blood you donated 4 weeks prior to the surgery."
D. "You will receive the blood you donated 4 weeks prior to the surgery."'
4. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will place the adapter on my finger to read my blood
oxygen saturation level."
B. "I will lie on my back with my knees bent."
C. "I will rest my hand over my abdomen to create resistance."
D. "I will take in a deep breath and hold it before exhaling."
D. "I will take in a deep breath and hold it before exhaling."
A nurse is caring for a client who has been diagnosed with cervical cancer. The client asks the nurse about palliative care. Which of the following responses should the nurse give?
A. "This treatment is for clients who have 6 months or less to live."
B. "This treatment is provided to clients when curative measures have been discontinued."
C. "Care is provided in 60 day increments and continued if the criteria is met."
D. "Care is delivered for serious illnesses and focuses on quality of life."
D. "Care is delivered for serious illnesses and focuses on quality of life."
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea?
A. Morphine
B. Ondansetron (Zofran)
C. Naloxone (Narcan)
D. Diazepam (Valium)
Ondansetron (Zofran)
The nurse is instructing a patient with iron deficiency anemia about appropriate menu choices. Which diet choice indicates that teaching has been effective?
1.Tofu with mixed vegetables in curry, milk, whole-wheat bun
2.Broiled fish, lettuce salad, grapefruit half, carrot sticks
3.Pork chop, mashed potatoes and gravy, cauliflower, tea
4.Roast beef, steamed spinach, tomato soup, orange juice
4.Roast beef, steamed spinach, tomato soup, orange juice