The physician orders a blood transfusion for a client. The nurse should anticipate using an I.V. access device of which size?

Correct Answer: C

Rationale: The correct answer is C (18G) because a blood transfusion requires a larger gauge size to allow for the rapid flow of blood products without causing hemolysis. 18G provides a larger diameter for quick transfusion. Option A (23G) and D (25G) are too small for efficient blood flow. Option B (21G) is slightly larger but may still impede the flow rate compared to 18G, making it less optimal for blood transfusion.

Correct Answer: C

Rationale: Rationale: Choice C is correct because encouraging fluid intake helps prevent urinary stasis and reduces the risk of catheter-associated urinary tract infections. Adequate hydration promotes urine flow, preventing sediment buildup in the catheter. Choices A, B, and D are incorrect. Choice A is unnecessary and can introduce infection risk. Choice B is incorrect because disconnecting the drainage system can introduce infection. Choice D is incorrect because burning and irritation at the meatus are not normal and should be reported to healthcare providers for assessment and intervention.

Correct Answer: D

Rationale: The correct answer is D: Sputum culture and sensitivity. This test is crucial in determining the specific bacteria causing pneumonia and their sensitivity to antibiotics, guiding appropriate treatment. A: Arterial blood gas measures oxygen and carbon dioxide levels, not helpful for antibiotic selection. B: Chest X-ray confirms pneumonia diagnosis but doesn't identify the causative organism. C: Complete blood count shows general infection markers, not specific for antibiotic selection.

Correct Answer: A

Rationale: The correct action for the nurse to take first is to obtain the baseline weight. This is important to assess the degree of fluid loss due to diarrhea. By comparing the baseline weight with subsequent weights, the nurse can determine the severity of dehydration and guide the appropriate treatment. Checking blood pressure (B), drawing blood for serum electrolyte levels (C), and asking about extremity numbness or tingling (D) are important assessments but should come after obtaining the baseline weight to prioritize immediate management of dehydration.

Correct Answer: B

Rationale: The correct answer is B because if the client asks about possible complications from the operation, the nurse should not have the client sign the consent until their questions are addressed by the primary health care provider. This ensures that the client fully understands the risks involved before giving consent. Answer A is incorrect because simply answering the questions and documenting teaching may not ensure that the client's concerns are adequately addressed. Answer C is incorrect because having the client sign the consent without addressing their concerns first is not in the client's best interest. Answer D is incorrect because reminding the client of previous teaching does not address the client's current concerns about possible complications.