The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?- Nurselytic

Question 1 of 5

The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?

A. Stop the infusion B. Slow the rate of infusion C. Take vital signs and observe for further deterioration D. Administer Benadryl and continue the infusion

Correct Answer: A

Rationale: The infusion should be stopped immediately to prevent further reaction.

Question 2 of 5

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

Correct Answer: A

Rationale: It is important to use contraception until sperm is confirmed absent in the ejaculate.

Question 3 of 5

A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

A. Assess the client's lung sounds bilaterally. B. Diminished left lower lobe sounds. C. Monitor ventilator settings for changes in oxygen levels. D. Increased sputum production and shortness of breath.

Correct Answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage.

Question 4 of 5

A client with diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor for closely?

A. Monitor for elevated blood pressure. B. Monitor for ketonuria. C. Monitor for peripheral edema. D. Monitor for hypokalemia.

Correct Answer: D

Rationale: Hypokalemia is a common complication of diabetes insipidus due to excessive urination and the resultant electrolyte imbalance.

Question 5 of 5

An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?

A. Begin dopamine infusion at 2 mcg/kg/minute. B. Begin potassium chloride 10 mEq over 1 hour. C. Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes. D. Administer promethazine 25 mg IV push.

Correct Answer: C

Rationale: A fluid bolus is the first step in stabilizing a client with hypovolemic symptoms.

Nurselytic

HESI RN

HESI RN

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