Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?

Correct Answer: D

Rationale: Patients who have undergone splenectomy are at risk for overwhelming postsplenectomy infection (OPSI) due to the absence of a functioning spleen, which is important in fighting certain types of infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae. Symptoms of OPSI can include fever, chills, weakness, and rapid breathing. Fever is a significant sign that alerts the nurse to the possibility of OPSI in a post-splenectomy patient, as it may indicate an infection that the body is struggling to fight without the spleen's immune support. This is a crucial symptom to monitor and act upon promptly to prevent serious complications in these individuals.

Correct Answer: D

Rationale: During the first 24 hours after a client is diagnosed with Addisonian crisis, it is crucial for the nurse to frequently assess the client's vital signs. Addisonian crisis is a life-threatening condition resulting from acute adrenal insufficiency. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can provide valuable information about the client's condition and response to treatment. Changes in vital signs may indicate worsening or improvement in the client's health status, helping the nurse to make timely interventions and adjustments in the client's care plan. Regular assessment of vital signs is essential in managing the client's stability and preventing complications during this critical period.

Correct Answer: C

Rationale: The precaution a nurse should take to minimize the risk of deaths occurring when potassium chloride is used incorrectly to flush a lock or central venous catheter is to read labels carefully on vials containing flush solutions for locks. This is essential to ensure that the correct solution is being used and to prevent accidental administration of potassium chloride, which can be fatal if used inappropriately. By carefully checking the labels, the nurse can confirm that they are using the correct flush solution and avoid any harmful errors. This simple precaution can help in ensuring patient safety and preventing adverse outcomes.

Correct Answer: D

Rationale: A neonate born to a mother with blood type AB and a father with blood type O is at risk for ABO blood incompatibility, particularly if the neonate is blood type A or B. The major sign of ABO blood incompatibility in the neonate is the development of jaundice within the first 24 hours of life. This occurs due to the mismatch in blood types between the mother and the neonate, leading to the destruction of the neonate's red blood cells. This destruction releases bilirubin, causing jaundice. It is important to note that unlike Rh incompatibility, ABO incompatibility usually does not lead to severe complications requiring treatment. A positive Coombs test result is not typically seen in ABO blood incompatibility.

Correct Answer: D

Rationale: Heavy meals close to bedtime disrupt sleep.