When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?

Correct Answer: A

Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction. Incorrect choices: B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction. C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing

Correct Answer: A

Rationale: The correct answer is A because it demonstrates an understanding of the key factors in managing hyperosmolar hyperglycemic nonketotic syndrome (HHNS), which include avoiding dehydration and being aware of changes in urination, thirst, and hunger. This statement shows awareness of the importance of maintaining hydration and recognizing early signs of worsening symptoms. Choice B is incorrect as consuming sugary soda can exacerbate the condition by further increasing blood sugar levels. Choice C is incorrect because while monitoring blood glucose levels is important, it is not the primary method of preventing HHNS. Choice D is incorrect because consuming high-carbohydrate snacks can contribute to elevated blood glucose levels, which is counterproductive in managing HHNS.

Correct Answer: B

Rationale: The correct answer is B: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. Rationale: 1. Latex condoms create a physical barrier that helps prevent the exchange of bodily fluids containing HIV. 2. Spermicide can further reduce the risk of HIV transmission by killing some viruses and bacteria. 3. Research shows that consistent and correct use of condoms is highly effective in reducing the risk of HIV transmission. 4. Other choices are incorrect: - A: Unprotected sex between HIV-positive individuals can lead to the transmission of drug-resistant strains or different strains of HIV. - C: Contraceptive methods like birth control pills do not protect against HIV transmission. - D: The intrauterine device is not specifically recommended for clients with HIV due to potential risks of infection.

Correct Answer: C

Rationale: The correct answer is C because data validation involves verifying the accuracy and consistency of data by comparing it with other reliable sources. This ensures that the data is correct and reliable for analysis. Choice A is incorrect because data validation typically occurs after data collection, which is followed by data interpretation. Choice B is incorrect because validation is not about professional standards but about verifying data accuracy. Choice D is incorrect because data interpretation focuses on deriving meaning and insights from data, not on professional standards. In summary, understanding the differences between data validation and interpretation is crucial for ensuring data accuracy and reliability.

Correct Answer: A

Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances. Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.

Correct Answer: D

Rationale: The correct answer is D because Buck's extension traction is not used definitively to treat fractures in children due to their growing bones. Instead, it is used temporarily in adults to control muscle spasm and pain. - A: Correct - Buck's extension traction is indeed used temporarily in adults to control muscle spasm and pain. - B: Correct - Buck's extension traction is applied by an orthopedic surgeon under aseptic conditions using wires and pins. - C: Correct - The pulling force in Buck's extension traction is indeed transmitted to the musculoskeletal structures. Therefore, the incorrect option is D as Buck's extension traction is not used definitively to treat fractures in children.

Correct Answer: A

Rationale: The correct answer is A. Blood type A is considered the rarest because it is less common in the general population compared to other blood types. The rarity of blood type A is due to the combination of genetic factors that determine blood type. In contrast, blood types B and O are more common in the population, while blood type AB is considered the universal recipient type and is therefore not the rarest. Blood type A is less prevalent, making it the correct answer in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Inform the registered nurse. This is the best course of action as the LPN should escalate the situation to a higher level of care by involving the registered nurse who can further assess the patient's concerns and provide appropriate interventions. A. Reassuring the patient may not address the underlying fear and may not be sufficient to alleviate their anxiety. B. Providing statistics about surgery death rates may further escalate the patient's fears and anxiety, causing more harm than good. D. Involving the family to comfort the patient may not address the patient's specific concerns and may not be within the family's scope of understanding or expertise to effectively address the situation. Informing the registered nurse allows for a more comprehensive assessment and appropriate intervention to address the patient's fears and concerns in a holistic manner.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor. 2. ACE inhibitors like enalapril maleate block the conversion of angiotensin I to angiotensin II. 3. By inhibiting the formation of angiotensin II, enalapril maleate decreases the levels of angiotensin II. 4. Angiotensin II is a potent vasoconstrictor, so decreasing its levels leads to vasodilation and decreased blood pressure. Summary of why other choices are incorrect: - Choice B: Enalapril maleate primarily dilates arterioles by decreasing angiotensin II levels, not veins. - Choice C: Enalapril maleate does not directly adjust extracellular volume; it primarily affects the renin-angiotensin-aldosterone system. - Choice D: Enalapril maleate