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Questions 149

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Question 1 of 5

A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?

Correct Answer: A

Rationale: Low back pain is a hallmark of acute hemolytic transfusion reaction due to hemolysis and kidney involvement. Fever, urticaria, or neck vein distention suggest other complications.

Question 2 of 5

A nurse is preparing to lift a client up in bed. Which of the following should the nurse do to help avoid injuring his back?

Correct Answer: C

Rationale: Tightening stomach and leg muscles stabilizes the core, reducing back strain during lifting.

Question 3 of 5

The nurse is caring for a 12-year-old client with appendicitis. The client's mother is a Jehovah's Witness and refuses to sign the blood permit. What nursing action is most appropriate?

Correct Answer: D

Rationale: Notifying the physician respects the mother's beliefs while ensuring the medical team addresses the refusal appropriately.

Question 4 of 5

A nurse is preparing to administer a MMR vaccine to a 35-year-old male. The nurse should

Correct Answer: D

Rationale: MMR is an intramuscular vaccine, requiring a 90-degree angle injection (typically deltoid). Dorsogluteal is not preferred, and pinching is for subcutaneous injections.

Question 5 of 5

The nurse is educating a client about lifestyle modifications to manage hypertension. Which of the following modifications should the nurse recommend? Select all that apply.

Correct Answer: B,C,D,F

Rationale: Hypertension management includes regular aerobic exercise (
B), the DASH diet (
C), weight loss (
D), and smoking cessation (F). Limiting fluids (
A) is not standard, and moderate alcohol (E) is acceptable.

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