The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the
client's safety, which measure should the nurse t
... [Show More] ake during administration of blood products?
Correct1
Stay with client during first 15 minutes of infusion.
2
Flush packed red blood cells with 5% dextrose and 0.45% normal saline.
3
Discontinue the intravenous catheter if a blood transfusion reaction occurs.
4
Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge
needle.
The nurse should remain with the client for the first 15 to 30 minutes. Any severe reaction usually occurs
with the infusion of the first 50 mL of blood. Blood components are viscous, requiring a large needle to
be used for venous access. A 20-gauge needle is not used to access a central catheter line. Normal saline
is the solution to administer with blood productions. Lactated Ringer and dextrose in water are not used
for infusion because of hemolysis.
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8.A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow
pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the
nurse suspect?
Correct1
Retinol (vitamin A)
2
Thiamine (vitamin B1)
3
Pyridoxine (vitamin B6)
4
Ascorbic acid (vitamin C)
These adaptations, as well as anemia, irritability, pruritus, and an enlarged spleen, occur with vitamin A
toxicity. Excess thiamine is excreted in the urine and rarely, if ever, causes toxicity; an excessive dose may
elicit an allergic reaction in some individuals. Excess vitamin C (ascorbic acid) does not cause these
adaptations or toxicity; however, vitamin C may cause diarrhea or renal calculi. Pyridoxine (vitamin B6) is
relatively nontoxic, and excess amounts are excreted in the urine.
STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all
exams is not realistic, but scoring an 85% may be a better goal.
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10.
A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the
nurse share about insulin and exercise?
Correct1
"Exercise increases the need for carbohydrates and decreases the need for insulin."
2
"Exercise increases the need for insulin and increases the need for carbohydrates."3
"Regular physical activity decreases the need for insulin and decreases the need for carbohydrates."
4
"Intensive physical activity decreases the need for carbohydrates but does not affect the need for
insulin."
Exercise increases the uptake of glucose by active muscle cells without the need for insulin;
carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise.
The need for insulin is decreased.
Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of
resources over an extended period of time ensures your understanding and increases your confidence
about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You
are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases
awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you
from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding
to your strength and inner conviction to achieve success.
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12.
A client with a new diagnosis of type 1 diabetes is told that lifelong insulin will be needed. The client
becomes agitated and says, "I am scared of shots. If that is my only option, I’ll just have to go into a coma
and die!" What is the nurse’s best response?
Correct1
"Injections are not the only option available for insulin."
2
"It won’t be so bad; you will get used to it if you will only try."
3
"This is one of those times when you need to act like an adult."
4"Clients have the right to refuse treatment, but I need you to sign this form that removes us from liability
for your decision."
An insulin nasal spray was approved by the Food and Drug Administration (FDA) in 2014 and is available
for clients who do not want insulin injections. The nurse should use therapeutic communication in
interacting with clients. Intimidating the client by suggesting that actions are childlike and suggesting
that the client’s concerns are not significant are not therapeutic responses. The nurse’s primary concern
should be for the client’s well-being, not protection from liability.
Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the
alternatives that you know are incorrect and proceed from that point. The same goes for a multipleresponse question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank
question poses a problem, read the situation and essential information carefully and then formulate your
response.
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14.
A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this
medication after discharge. How will the nurse respond?
Correct1
"Antiseizure drugs will probably be continued for life."
2
"Phenytoin prevents any further occurrence of seizures."
3
"This drug needs to be taken during periods of emotional stress."
4
"Your antiseizure drug usually can be stopped after a year's absence of seizures."
Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral
cortex, requiring prolonged or lifelong therapy. Seizures may occur despite drug therapy; the dosage may
need to be adjusted. A therapeutic blood level must be maintained through consistent administration ofthe drug irrespective of emotional stress. Absence of seizures will probably result from medication
effectiveness rather than from correction of the pathophysiologic condition.
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17.
A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is
initiated. What drug action will the nurse include when describing the purpose of this drug to the client?
Correct1
Prevents extension of the clot
2
Reduces the size of the thrombus
3
Dissolves the blood clot in the vein
4
Facilitates absorption of red blood cells
Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets.
Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins.
Heparin does not facilitate the absorption of red blood cells.
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23.A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is
made. Upon a review of the client's prescribed medication list, the nurse determines that what is the
likely cause of the clinical findings?
Correct1
Digoxin (Lanoxin)
2
Furosemide (Lasix)
3
Propranolol (Inderal)
4
Spironolactone (Aldactone)
These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia.
Although furosemide most likely contributed to the hypokalemia, the client's symptoms are consistent
with digitalis toxicity. Although propranolol can cause nausea, vomiting, and blurred vision, the presence
of hypokalemia and yellow vision are more suggestive of digitalis toxicity. A side effect of spironolactone
is hyperkalemia, not hypokalemia.
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A client with cancer of the thyroid is scheduled for a thyroidectomy. What should the nurse teach the
client?
Incorrect1
The dietary intake of carbohydrates must be restricted.
Correct2
Thyroxine replacement therapy will be required indefinitely.
3
Chemotherapy may be used in conjunction with the surgery.
4
A tracheostomy requires an alternative means of communication.
Thyroxine is given postoperatively to suppress thyroid-stimulating hormone (TSH) and prevent
hypothyroidism. Increased intake of carbohydrates and proteins is needed because of the increased
metabolic activity associated with hyperthyroidism. Chemotherapy is uncommon; radiation may be used
to eradicate remaining tissue. A tracheostomy is not planned; it is needed only in an emergency related
to respiratory distress.Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive
attitude.
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2.
A client who had abdominal surgery is receiving patient-controlled analgesia intravenously to manage
pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the
client, with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour
and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment
reveals that the client is experiencing pain still. What should the nurse do first?
Incorrect1
Monitor the client's pain level for another hour.
Correct2
Determine the integrity of the intravenous delivery system.
3
Reprogram the pump to deliver a bolus dose every 8 minutes.
4
Arrange for the client to be evaluated by the healthcare provider.
Initially, integrity of the intravenous system should be verified to ensure that the client is receiving
medication. The intravenous tubing may be kinked or compressed or the catheter may be dislodged.
Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not
reprogram the pump to deliver larger or more frequent doses of medication without a healthcare
provider's prescription. The healthcare provider should be notified if the system is intact and the client is
not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased,
the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.
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