A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Vital Signs

0800:

Blood pressure 112/64 mm Hg

Heart rate 80/min

Respiratory rate 18/min

Temperature 37.1° C (98.8" F

Oxygen saturation 97% on room air

08151

Blood pressure 106/54 mm Hg Heart rate 100/min

Respiratory rate 22/min Temperature 37° C (98,6°F)

Oxygen saturation 95% on room air

Complete the following sentence by using the lists of options.
The client has manifestations of
an , as evidenced by the

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

A. Check the pH of the gastric aspirate. B. Observe the color of the gastric aspirate after adding blue dye to the formula. C. Auscultate over the epigastrium. D. Measure the length of the inserted NG tube.

Correct Answer is A

Explanation

A: Correct. Checking the pH of the gastric aspirate is the most reliable method to verify the correct placement of the NG tube. Gastric aspirate typically has an acidic pH (pH < 5), indicating that the tube is in the stomach.
B: Observing the color of the gastric aspirate after adding blue dye to the formula is not a standard or recommended method for verifying NG tube placement.
C: Auscultating over the epigastrium may help to identify the presence of air in the stomach, but it does not confirm that the NG tube is correctly placed in the stomach or the intestines.
D: Measuring the length of the inserted NG tube can help determine the distance from the nose to the stomach, but it does not ensure correct placement in the stomach.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?

Correct Answer is A

Explanation

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs?

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of her behavior change?

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a lowpotassium diet. Which of the following food by the client demonstrates an understanding of the teaching?