Correct Answer: A

Rationale: The correct answer is A: Hgb (hemoglobin). Epoetin alfa is a medication used to treat anemia by stimulating red blood cell production. Monitoring the hemoglobin levels helps determine the effectiveness of the medication in increasing red blood cells. Hemoglobin reflects the oxygen-carrying capacity of the blood, so an increase in hemoglobin levels indicates a positive response to the medication. Troponin (
B) is a marker for heart damage, unrelated to epoetin alfa. Thyroxine (
C) and AST (
D) are not relevant to monitoring the effectiveness of epoetin alfa.

Correct Answer: 167 mL/hr

Rationale:
To calculate the IV pump rate, divide the total volume (1L = 1000mL) by the total time in hours (6hr).
1000mL / 6hr = 166.67 mL/hr, rounded to the nearest whole number is 167 mL/hr.
This rate ensures the administration of 1L over 6 hours.
Option A: Incorrect as it does not match the calculated rate.
Options B-G: Irrelevant as they do not align with the correct calculation.

Correct Answer: B

Rationale: The correct answer is B: Obtain 0.9% sodium chloride solution for IV infusion. This is the correct action because it is important to prime the IV tubing with a normal saline solution before starting the transfusion to prevent hemolysis of the packed RBCs. Normal saline is isotonic and compatible with most blood products, reducing the risk of adverse reactions.


Choice A is incorrect because packed RBCs should be transfused within 4 hours, not 6 hours.
Choice C is incorrect because filterless IV tubing should not be used for blood transfusions as it can lead to the administration of clots or debris.
Choice D is incorrect because the nurse should remain at the client's bedside for the first 15 minutes of the transfusion, not 5 minutes, to monitor for any immediate adverse reactions.

Correct Answer: D

Rationale: The correct answer is D: Reduced bronchial inflammation. Montelukast is a leukotriene receptor antagonist used to manage asthma and allergic rhinitis by reducing inflammation in the airways. This medication works by blocking leukotrienes, which are chemicals that contribute to inflammation, bronchoconstriction, and mucus production in the lungs. By reducing bronchial inflammation, montelukast helps to improve breathing and prevent asthma symptoms.

A: Improved peripheral vasodilation - This is not an expected therapeutic effect of montelukast as it does not directly affect peripheral vasodilation.
B: Neutralized gastric acid - Montelukast does not have any effect on gastric acid secretion or neutralization.
C: Increased WBC count - Montelukast does not affect white blood cell count; it specifically targets leukotrienes involved in the inflammatory response.

In summary, the correct answer is D because montelukast's primary therapeutic effect is to

Correct Answer: A

Rationale: The correct answer is A: Check the client's current level of pain. The nurse should prioritize assessing the client's pain as grimacing and increased respiratory rate can indicate pain. By assessing the pain level first, the nurse can address the client's immediate needs and provide appropriate pain relief interventions. Option B is incorrect as distraction may not address the underlying cause of the client's discomfort. Option C is also incorrect as repositioning may not alleviate pain. Option D is incorrect as a cold compress may not be the appropriate intervention without assessing the cause of the pain first.