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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Free Nursing Study Resources

Correct Answer is ["B","E"]

Explanation

Choice A reason: Elevating the buttocks with a pillow is not specifically indicated in the scenario provided. While it might assist in other situations to reduce swelling by using gravity, it isn't a standard intervention for the described situation post-TURP.

Choice B reason: Applying a cold pack to the scrotal and penile areas can help reduce the swelling and discomfort associated with edema. Cold therapy is effective in constricting blood vessels and reducing inflammation, making it an appropriate immediate intervention.

Choice C reason: While obtaining a urinalysis might provide information on the presence of infection or other abnormalities, it does not directly address the immediate issue of the observed edema. Therefore, it is not a primary intervention in this scenario.

Choice D reason: Removing the indwelling urinary catheter without specific orders can lead to complications and is not advised as an initial intervention. The catheter serves a critical purpose post-surgery and should be handled according to protocol or provider direction.

Choice E reason: Notifying the healthcare provider immediately is crucial when unexpected postoperative complications such as edema occur. Prompt communication allows for timely medical intervention and ensures that the patient receives the necessary care.

A. Place an indwelling urinary catheter and institute strict intake and output measurements. B. Secure client consent for coronary angiography and percutaneous coronary intervention. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.

Correct Answer is C

Explanation

Choice A reason: Placing an indwelling urinary catheter and instituting strict intake and output measurements can be done later if needed, but addressing the chest pain is the priority.

Choice B reason: Securing consent for coronary angiography and intervention is important but should be done after addressing the immediate chest pain and potential myocardial infarction.

Choice C reason: Administering aspirin is crucial as it acts as an antiplatelet agent, helping to reduce the risk of further clot formation and improving outcomes in the setting of acute coronary syndrome.

Choice D reason: Evaluating extremities for perfusion is important but secondary to administering aspirin in this acute situation.

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Naxlex Comprehensive Predictor Exams

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","E"]

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

A client with Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?