A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse’s first best action?

Correct Answer: D

Rationale: The correct answer is D: Stop the infusion. This is the best action because the client is likely experiencing a transfusion reaction. Stopping the infusion immediately is crucial to prevent further complications. Reporting the signs and symptoms to the healthcare provider (A) can cause a delay in addressing the reaction. While monitoring vital signs (B) and assessing respiratory status (C) are important, stopping the infusion takes precedence to ensure the client's safety and prevent a severe reaction.

Correct Answer: B

Rationale: The correct answer is B: To administer antineoplastic chemotherapy. This is because antineoplastic chemotherapy agents are highly irritating and toxic to the surrounding tissues. Using midline and mid clavicular sites for IV therapy in this case can increase the risk of extravasation, leading to tissue damage and potential complications. Incorrect choices: A: To administer solutions with a pH greater than 5 and less than 9 - pH of the solution does not directly affect the choice of site for IV therapy. C: To administer slow, low-volume infusions - Midline and mid clavicular sites can be appropriate for slow, low-volume infusions. D: To administer high-pressure bolus injections - While midline and mid clavicular sites may not be ideal for high-pressure bolus injections, the question specifically mentions IV therapy, not bolus injections.

Correct Answer: B

Rationale: The correct answer is B: inadequate supply of oxygen to the myocardium. Angina pectoris is chest pain or discomfort caused by reduced blood flow to the heart muscle. This lack of oxygenated blood supply to the myocardium leads to ischemia, resulting in the characteristic chest pain. Choice A is incorrect as it refers to a decrease in alveolar surface area for gas exchange, which is related to conditions like emphysema, not angina. Choice C is incorrect as it pertains to pulmonary circulation, not coronary circulation. Choice D is incorrect as an increase in alveolar surface area would not be a cause of angina pectoris.

Correct Answer: C

Rationale: Rationale: - A: Diuretics are not necessary before the test and may affect test results. - B: Dehydration is not recommended before the test as it can impact cardiac function. - C: Medication to relieve cough is necessary to reduce any potential interference with the scan. - D: Administering analgesics is not required for the test and may not be relevant to the client's condition.

Correct Answer: A

Rationale: The correct answer is A because a poultice of sodium bicarbonate and water can help neutralize the venom and reduce pain from wasp and bee bites. Sodium bicarbonate has alkaline properties that can counteract the acidic venom. Option B is incorrect as household ammonia can cause skin irritation and should not be applied to insect bites. Option C is incorrect because only option A is a safe and effective treatment for wasp and bee bites. Option D is incorrect as there is a suitable emergency treatment available.

Correct Answer: D

Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.

Correct Answer: A

Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.

Correct Answer: C

Rationale: The correct answer is C: Human, T-cell lymphotrophic virus, as it is the causative agent for HIV/AIDS. This virus specifically targets and infects the body's T-cells, weakening the immune system. Trichomonas vaginalis, Treponema pallidum, and Chlamydia trachomatis are all different pathogens that do not cause HIV/AIDS. Trichomonas vaginalis is a protozoan parasite that causes trichomoniasis, Treponema pallidum causes syphilis, and Chlamydia trachomatis causes chlamydia. Therefore, the correct answer is C based on the specific viral agent responsible for HIV/AIDS.

Correct Answer: C

Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.