Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?

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Question 1 of 9

Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?

Correct Answer: B

Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream. Choices A, C, and D are incorrect: A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein. C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device. D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.

Question 2 of 9

Charles is started on chemotherapy, which is aimed at restoring dopaminergic activities. An example of such a drug is:

Correct Answer: D

Rationale: The correct answer is D: Dopar. Dopar is a drug that increases dopamine levels by converting into dopamine in the brain. This directly restores dopaminergic activities. Artane (A) is an anticholinergic used for Parkinson's symptoms, Elavil (B) is a tricyclic antidepressant, and Benadryl (C) is an antihistamine, none of which directly target dopaminergic activities like Dopar does.

Question 3 of 9

Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?

Correct Answer: A

Rationale: The correct answer is A: Shrimp and tomatoes. Shrimp is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Tomatoes are rich in Vitamin C, which helps enhance iron absorption. Cheese, bananas, lobster, squash, lamb, and peaches do not provide significant amounts of iron essential for an anemic client. The combination of shrimp and tomatoes offers a balanced approach to increase iron levels effectively.

Question 4 of 9

The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:

Correct Answer: D

Rationale: The correct answer is D: Suggest referral to a sex counselor or other appropriate professional. This is the most appropriate intervention as it addresses the client's concern about impotence affecting his marriage by offering specialized help from a professional who can provide counseling and guidance on managing sexual issues related to diabetes. Referring the client to a sex counselor ensures that he receives expert support in addressing his specific concerns and helps improve his overall well-being and quality of life. A: Encouraging the client to ask questions about personality sexuality may not address the underlying issue of impotence and its impact on the marriage. B: Providing time for privacy is important but may not directly address the client's concerns about impotence. C: Providing support for the spouse or significant other is beneficial, but the primary focus should be on addressing the client's specific concerns about impotence.

Question 5 of 9

The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?

Correct Answer: C

Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection. Explanation of why other choices are incorrect: A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing. B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately. D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is

Question 6 of 9

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?

Correct Answer: A

Rationale: The correct answer is A: Provide the patient with a writing board each shift. This intervention addresses the impaired verbal communication by offering an alternative way for the patient to communicate. Writing board enables the patient to express thoughts and feelings, reducing the risk of loneliness. Choice B doesn't directly address the communication issue. Choice C is not relevant to the nursing diagnosis. Choice D, while promoting companionship, doesn't address the specific communication concern stated in the diagnosis.

Question 7 of 9

Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?

Correct Answer: A

Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.

Question 8 of 9

The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.

Question 9 of 9

A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?

Correct Answer: C

Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention. Rationale for why other choices are incorrect: A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%). B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg). D: WBC count of 8000 is within normal range (4000-11000/uL). In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.

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