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 C

Explanation

Choice A reason: Ear pain and fever are not specific symptoms of mononucleosis and may indicate other infections such as otitis media.

Choice B reason: Elevated WBC (white blood cell) count and sedimentation rate can be seen in many infections and inflammatory conditions, but they are not specifically diagnostic of mononucleosis.

Choice C reason: Mononucleosis, often caused by the Epstein-Barr virus (EBV), typically presents with a positive EBV test and malaise (general feeling of discomfort or illness). Other common symptoms include fever, sore throat, swollen lymph nodes, and fatigue.

Choice D reason: Increased BUN (blood urea nitrogen) and serum creatinine levels are indicators of kidney function and are not typically associated with mononucleosis.

A. Washing for a total of 20 seconds. B. Lathering using a circular movement. C. Turning the water off using bare hands. D. Holding hands below elbows when rinsing.

Correct Answer is C

Explanation

Choice A reason: Washing for a total of 20 seconds is correct and meets hand hygiene guidelines.

Choice B reason: Lathering using a circular movement is an appropriate technique for thorough handwashing.

Choice C reason: Turning the water off using bare hands can lead to recontamination of the hands. The UAP should use a paper towel to turn off the faucet.

Choice D reason: Holding hands below elbows when rinsing is correct to allow water to run off the hands and prevent contamination.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is C

Explanation

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

A client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

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 is admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

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?