When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?

Correct Answer: A

Rationale: Monitoring the client's temperature before, during, and after transfusion is essential to determine if chilling is the result of an emerging complication or of infusing cold blood. By consistently monitoring the client's temperature at different points in the transfusion process, healthcare providers can identify any significant changes that may indicate a complication. This allows for timely intervention and appropriate management of any issues related to the blood transfusion. Comparing the client's temperature with the temperature of the blood is important but alone it may not provide a comprehensive assessment of the client's condition during the transfusion process. So, the best course of action is to monitor the client's temperature at various time points to ensure accurate assessment and early detection of any complications.

Correct Answer: A

Rationale: The nurse should examine the entire system and tubing for air leaks when observing vigorous bubbling in the water-seal chamber of a chest-drainage system. Vigorous bubbling indicates that there is air escaping from the system, which can lead to suboptimal drainage and potential complications. By identifying and correcting any air leaks, the nurse can ensure the chest-drainage system functions effectively, allowing for proper drainage and the prevention of complications such as pneumothorax. Lowering the level of suction or asking the patient to cough forcefully would not address the underlying issue of air leaks and may not resolve the problem effectively.

Correct Answer: A

Rationale: Prophylactic antibiotics are given to prevent the recurrence or complications of endocarditis in patients with a history of the condition. Endocarditis is an infection of the inner lining of the heart chambers and valves. One of the serious complications of endocarditis is the formation of vegetative emboli, which are clusters of bacteria and fibrin that can break off and travel through the bloodstream, potentially causing blockages in various organs. By preventing endocarditis, the antibiotics also help reduce the risk of vegetative emboli formation during surgical procedures or other situations where bacteria may enter the bloodstream. Therefore, the nurse's explanation to the patient about the prophylactic antibiotics is focused on preventing complications related to endocarditis, including the formation of vegetative emboli.

Correct Answer: C

Rationale: Immunity to a disease after recovery is possible because the first exposure to the pathogen has stimulated the formation of memory cells. Memory cells are a type of immune cell that "remembers" the specific pathogen encountered during the initial infection. When the same pathogen tries to infect the individual again, these memory cells quickly recognize the pathogen and mount a faster and stronger immune response, leading to a quicker recovery and preventing the person from getting sick again from the same pathogen. This immune memory is the basis of acquired immunity, providing long-lasting protection against future infections by the same pathogen.

Correct Answer: B

Rationale: The nurse would expect to see respiratory stridor (iii), tachycardia (v), and dyspnea (vi) upon admission of the patient who was stung by a bee, particularly if the patient has allergies to bee stings. These symptoms are indicative of an allergic reaction, which can progress to anaphylaxis in severe cases. Symptoms such as pallor around the sting bites (i), retinal hemorrhage (iv), and numbness and tingling in the extremities (ii) are not typically associated with an allergic reaction to a bee sting.