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Questions 158

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Question 1 of 5

A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?

Correct Answer: A

Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.

Question 2 of 5

The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:

Correct Answer: A

Rationale: Clients who have obstruction in the biliary tract so that bile is not released into the duodenum experience a change in stools from brown to gray or clay colored. This type of stool can occur with other GI problems, such as bacterial or viral infections, and other disease problems, and is not a common finding with biliary obstructions such as cholecystitis and cholelithiasis. This type of stool is usually associated with a GI or bowel problem, such as lower GI bleeding, rather than with biliary obstructions. This type of stool is usually associated with a GI or bowel problem, such as upper GI bleeding, rather than with biliary obstructions.

Question 3 of 5

A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

Correct Answer: D

Rationale: Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. A person may be in pain even with normal vital signs. A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.

Question 4 of 5

A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

Correct Answer: C

Rationale: This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. This action is a medical procedure, not a nursing procedure. An occlusive dressing will prevent further air leak until the physician institutes further treatment. The decision to reinsert the tube is a medical decision, not a nursing one.

Question 5 of 5

A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25 mg daily. Which of the following statements indicates that the client needs further teaching?

Correct Answer: B

Rationale: Taking digoxin with an antacid can decrease its absorption, reducing effectiveness, so this statement indicates a need for further teaching.

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