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Questions 158

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Question 1 of 5

The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?

Correct Answer: D

Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.

Question 2 of 5

Which situation would be reportable to the state board of nursing?

Correct Answer: B

Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.

Question 3 of 5

A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?

Correct Answer: C

Rationale: The AIDS virus cannot be transmitted to the donor through the blood donation procedure. The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. For reasons of confidentiality, information about individuals infected with AIDS is not made public.

Question 4 of 5

A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods.

Correct Answer: A

Rationale: Raw foods like tossed salad (
A) can harbor pathogens, risky for AIDS patients with diarrhea. Baked chicken (
B), broiled fish (
C), and steamed rice (
D) are cooked and safer, indicating further teaching is needed for A.

Question 5 of 5

A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:

Correct Answer: D

Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.

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