The nurse is preparing to administer a blood transfusion. Which action should the nurse take first?

Correct Answer: B

Rationale: The correct answer is B. Comparing the client's identification wristband with the tag on the unit of blood is crucial to ensure proper patient identification and prevent errors in blood transfusion. This step helps verify patient identity and blood compatibility before administration. Incorrect Choices: A: Typing and crossmatching can be done after patient identification to confirm compatibility. C: Starting an IV infusion of normal saline is important but not the first step in blood transfusion. D: Measuring vital signs is important but should not be the first action before verifying patient identity for blood transfusion.

Correct Answer: A

Rationale: The correct answer is A: Lung sounds. When a patient receives a hypertonic solution like 3% NaCl for hyponatremia, there is a risk of fluid shifting from the intravascular space to the interstitial spaces, potentially causing pulmonary edema and respiratory distress. Monitoring lung sounds is crucial to detect any signs of fluid overload and intervene promptly. B: Urinary output is important but not as critical as monitoring lung sounds in this context. C: Peripheral pulses and D: Peripheral edema are not directly related to the potential complications of receiving a hypertonic solution like 3% NaCl.

Correct Answer: B

Rationale: The correct answer is B: diagnosing. In the nursing process, diagnosing involves analyzing assessment data to identify actual and potential health problems. In this scenario, the nurse is identifying a potential issue with normal growth and development based on assessment findings. Assessing (A) is the data collection step, planning (C) involves developing interventions, and implementing (D) is the action step. Diagnosing is the appropriate step to identify the specific problem and guide the care plan.

Correct Answer: C

Rationale: The correct answer is C because a value is a belief about the worth of something that guides behavior. Values are deeply held beliefs that influence our attitudes and actions. Choice A is incorrect as it refers to ethics and morality. Choice B is incorrect as it describes the process of determining values, not the values themselves. Choice D is incorrect as it describes virtues or character traits, not values. In summary, values are fundamental beliefs about what is important or worthwhile, guiding our behavior and decisions.

Correct Answer: A

Rationale: Parental approval, success at school, and receiving a promotion at work will have a positive impact on the individual's self-concept, as these situations promote good feelings about self-concept. A chronic illness usually has a negative impact on self-concept, as the client is related to the changes. Excessive use of alcohol is a symptom of a poor self-concept.

Correct Answer: A

Rationale: The patient has a broken femur and her blood pressure is elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment.

Correct Answer: D

Rationale: The correct answer is D: Counselor. The nurse assumes the role of counselor when guiding a client in making healthcare decisions by providing emotional support, helping the client explore options, and facilitating informed decision-making. A leader typically involves taking charge or directing a group, which may not always be appropriate in this context. An advocate focuses on promoting the client's rights and best interests but may not necessarily provide the counseling aspect. A liaison acts as a link or intermediary between the client and other healthcare providers, which is different from providing direct counseling and support.

Correct Answer: B

Rationale: The correct answer is B: Hyperinflation of lungs documented by chest x-ray. In COPD exacerbation, the airways become inflamed and narrowed, leading to air trapping and hyperinflation of the lungs. This is evidenced on chest x-ray by increased lung volume and flattened diaphragms due to overinflation. Choices A, C, and D are incorrect because in COPD exacerbation, oxygen saturation typically decreases with ambulation due to impaired gas exchange, a widened diaphragm is not a typical finding on chest x-ray in COPD exacerbation, and a shortened expiratory phase is more commonly seen in obstructive lung diseases like asthma rather than COPD exacerbation.

Correct Answer: D

Rationale: The correct answer is D: Red blood cells. Immunocompetence refers to the ability of the immune system to effectively respond to pathogens. Red blood cells are not directly involved in immune responses. Antibody-mediated immunity involves the production of antibodies by B cells to target pathogens. Cell-mediated immunity involves the activation of T cells to directly attack infected cells. Inflammation is a non-specific immune response that helps to eliminate pathogens. Red blood cells primarily function in oxygen transport and do not play a direct role in immune responses. Therefore, the correct answer is D as red blood cells do not need to be functional for a person to be immunocompetent.