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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. The client's body should be placed on the floor: This is not a specific cultural practice in Islam. In Islamic tradition, the deceased person is usually placed on a raised surface, like a table or bed, to allow family and friends to gather around for prayers and final respects.

B. The client's oldest child will bathe the body: This is not a specific cultural practice in Islam.

In Islamic tradition, the body is usually washed by individuals of the same gender who are experienced in the ritual washing of the deceased, known as "Ghusl."

C. The client's face should be turned toward Mecca: Correct. In Islamic tradition, when a person dies, it is customary to position the body with the head facing the Kaaba in Mecca, which is the holy city in Islam and the direction toward which Muslims pray.

D. The client's body will be adorned with amulets: This is not a specific cultural practice in Islam. While some individuals in various cultures may use amulets or charms for protection, it is not a universal Islamic practice for the deceased.

A. Explain the negative consequences of the refusal. B. Discuss with the client's partner why the treatment is necessary. C. Document the client's refusal of the treatment. D. Try to convince the client that the treatment is needed.

Correct Answer is C

Explanation

A: While explaining the negative consequences of refusal is important, it may not change the client's decision, and respect for the client's autonomy must be upheld.
B: Discussing the treatment with the client's partner without the client's consent may breach patient confidentiality and privacy.
C: Correct. The nurse should document the client's refusal of the medical treatment in the client's medical record. This documentation is essential for legal and ethical purposes and to ensure that the refusal is adequately communicated to the healthcare team.
D: Trying to convince the client to undergo the treatment is not appropriate and may violate the principle of informed consent. The client has the right to refuse treatment after being adequately informed of the risks and benefits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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 taking notes of client information on a piece of paper while receiving a report. Which of the following actions should the nurse take to dispose of the paper?

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?