Following a gunshot wound, an adult client has a hemoglobin level of 4 g/dL (40 g/L). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement?

Administer normal saline solution until Type AB negative is available.

Obtain additional consent for administration of Type A negative blood.

Recheck the client's hemoglobin, blood type, and Rh factor.

Transfuse Type A negative blood until Type AB negative is available.

Answer and Explanation

The Correct Answer is D

Choice A reason: Administering normal saline solution alone will not address the severe anemia caused by the low hemoglobin level.

Choice B reason: Obtaining additional consent is necessary, but it is not the immediate action required in this emergency situation.

Choice C reason: Rechecking the client's hemoglobin, blood type, and Rh factor is important, but the immediate priority is to address the severe anemia.

Choice D reason: Transfusing Type A negative blood is appropriate because it is compatible with AB negative blood and is necessary to treat the client's critical anemia.

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Correct Answer is C

Explanation

Choice A reason: Mixing the next dose with food is not recommended because digoxin is better absorbed on an empty stomach and food may interfere with its absorption. Additionally, this option does not address the immediate issue of the infant vomiting after the dose.

Choice B reason: Administering a half dose is not appropriate because it may lead to incorrect dosing and potential under-treatment or toxicity. The exact dose must be given according to medical guidelines.

Choice C reason: Withholding the dose is the best course of action. If an infant vomits after receiving a dose of medication, particularly a critical one like digoxin, it is essential to wait until the next scheduled dose to avoid potential overdose or toxic effects.

Choice D reason: Giving another dose is not recommended because it could lead to toxicity, especially considering the infant might have partially absorbed the initial dose before vomiting.

A. Obtain a 12-lead electrocardiogram daily. B. Evaluate glucose levels before and after meals. C. Monitor and document strict intake and output. D. Assess the serum potassium level every 4 hours.

Correct Answer is D

Explanation

Choice A reason: Obtaining a 12-lead electrocardiogram is important but not as frequent as monitoring potassium levels in this situation.

Choice B reason: Evaluating glucose levels is important but secondary to monitoring potassium levels.

Choice C reason: Monitoring and documenting intake and output are important but not as critical as frequent potassium level assessment.

Choice D reason: Frequent assessment of serum potassium levels is crucial due to the high initial potassium level and the use of insulin, which affects potassium levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is C

Explanation

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

A client who fell and broke a wrist is admitted for 24-hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.