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

Correct Answer: D

Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.

Correct Answer: C

Rationale: The nurse can help monitor the effectiveness of therapy for a patient with a pneumothorax and chest drainage system by auscultating lung sounds. Auscultation can provide information about the air movement within the lungs and any changes in lung sounds, such as decreased or absent breath sounds on the affected side, which may indicate improvement or deterioration in the patient's condition. By regularly assessing lung sounds, the nurse can track the progress of the therapy and make informed decisions about the patient's care and treatment plan. Palpating for crepitus, documenting sputum characteristics, and monitoring suction levels are important aspects of care but are not specifically focused on assessing the effectiveness of therapy for a pneumothorax.

Correct Answer: C

Rationale: A positive Homans' sign indicates possible deep vein thrombosis (DVT) in the leg. When a patient has DVT, the clot may dislodge and travel to the lungs, causing a pulmonary embolism, which can be life-threatening. Therefore, ambulation and performing the Homans' sign can dislodge the clot and potentially cause an embolism. It is contraindicated to prevent this serious complication.

Correct Answer: C

Rationale: IgM is the first immunoglobulin produced during an acute infection. It is the first class of antibodies secreted by B cells in response to an antigenic challenge. IgM antibodies are produced initially in primary immune responses and play a crucial role in activating the complement system. IgG is produced after IgM and is the most abundant immunoglobulin in the secondary immune response. IgE is responsible for allergic reactions, and IgD's function is not fully understood but is believed to be involved in the activation of B cells.

Correct Answer: C

Rationale: Driving in the car with the windows open is not a recommended action for someone with allergies to pollen. Keeping the windows closed while driving can help minimize exposure to pollen particles in the air. By driving with the windows open, the individual is increasing their exposure to pollen and not effectively controlling their allergy symptoms. Staying indoors on dry, windy days (Choice A), refusing to walk outside in the spring (Choice B), and working in the garden on sunny days (Choice D) are all actions that demonstrate understanding of how to control allergies to pollen by avoiding potential triggers.