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Questions 148

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Question 1 of 5

A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should

Correct Answer: D

Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.

Question 2 of 5

Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.

Order the Items

Source Container

Ask the client to open and close the hand until the skin blanches.
Palpate the ulnar and radial pulses and apply pressure to both arteries.
Observe the hand for color.
Release the ulnar artery while maintaining pressure on the radial artery.

Correct Answer: A,B,D,C

Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.

Question 3 of 5

The nurse is caring for a patient with a colostomy. The patient asks, 'Will I ever be able to swim again?' The nurse's best response would be:

Correct Answer: A

Rationale: Swimming is possible with a colostomy if proper precautions, like a waterproof seal, are used to protect the stoma.

Question 4 of 5

The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?

Correct Answer: A

Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (
A). Intestinal aspirate (
B) has pH > 6, respiratory (
C) is > 7, and results are conclusive (
D).

Question 5 of 5

The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:

Correct Answer: C

Rationale: A permanent pacemaker is a contraindication for an MRI due to the risk of device malfunction in a magnetic field.

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