A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?
A client who is receiving a blood transfusion and reports low-back pain
A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x105/uL (4.2 to 5.4 x106/uL)
A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing
A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag
The Correct Answer is A
Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.
B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.
C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.
D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Remove a plug from the socket by pulling the cord.": Pulling a plug out by the cord can damage the wiring and expose live electrical components, increasing the risk of electric shock or fire. The plug should always be removed by grasping the base of the plug itself to ensure safety.
B. "Check for a tingling sensation around the cord.": A tingling sensation indicates faulty wiring or electrical leakage, which poses a serious safety hazard. Rather than checking for it, individuals should immediately stop using any cord that gives off a tingling sensation and report or replace it.
C. "Use three-pronged grounded plugs.": Grounded plugs provide an essential safety feature by redirecting excess electrical current safely into the ground. This reduces the risk of electrical fires and shocks, especially in appliances with metal casings or high power consumption.
D. "Cover extension cords with a rug.": Covering cords traps heat, prevents adequate ventilation, and increases the risk of overheating and fire. Extension cords should remain uncovered and placed in areas where they will not be walked on or damaged.
Correct Answer is B
Explanation
Rationale:
A. Bradycardia: Ectopic pregnancy does not typically cause bradycardia. If cardiovascular changes occur, tachycardia is more common due to pain, blood loss, or hypovolemic shock in the event of rupture.
B. Abdominal pain: Abdominal or pelvic pain is a hallmark sign of ectopic pregnancy. Pain may be localized to one side, often corresponding to the site of implantation, and can become severe if tubal rupture occurs.
C. Hypertension: Hypertension is not associated with ectopic pregnancy. Blood pressure may decrease if significant internal bleeding occurs, potentially leading to hypotensive shock.
D. Hydramnios: Hydramnios (excess amniotic fluid) occurs in certain intrauterine complications but is not a feature of ectopic pregnancy, as the gestation occurs outside the uterine cavity.
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