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Questions 149

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Question 1 of 5

The nurse is preparing to administer a unit of red blood cells (RBCs) to an anemic client. From starting the infusion (puncturing the blood pack) to completion, infusion of the pack should occur within which time period?

Correct Answer: C

Rationale: RBC transfusions must be completed within 4 hours to minimize bacterial growth and ensure safety.

Question 2 of 5

A client has increasing pain in both hands. On examination, the nurse notes that the metacarpophalangeal and proximal interphalangeal joints are enlarged and swollen, swanneck deformity is evident, and the fingers on both hands show ulnar deviation. These findings are consistent with which of the following disorders?

Correct Answer: B

Rationale: Swanneck deformity, ulnar deviation, and swollen MCP/PIP joints are classic for rheumatoid arthritis (
B). Osteoarthritis (
A) affects distal joints, gout (
C) causes tophi, and psoriatic arthritis (
D) involves skin lesions.

Question 3 of 5

The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?

Correct Answer: C

Rationale:
To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.

Question 4 of 5

The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?

Correct Answer: D

Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.

Question 5 of 5

The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?

Correct Answer: B

Rationale: Applying oxygen is the priority to ensure airway patency and oxygenation in a client with facial and neck burns, which can cause airway compromise.

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