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 B

Explanation

Choice A reason: Scarlet fever and pneumonia require droplet precautions, not airborne.

Choice B reason: A positive Mantoux test and positive sputum cultures for AFB indicate tuberculosis, which requires airborne precautions and a negative airflow room.

Choice C reason: Scabies requires contact precautions, not airborne.

Choice D reason: Genital Herpes simplex II requires standard precautions, not airborne.

A. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client. B. Introduce him to the newly admitted client and ask him to join in the conversation. C. Encourage him to go to the nurse's station and talk with another nurse. D. Inform him that the nurse is busy admitting a new client and will talk to him later.

Correct Answer is D

Explanation

Choice A reason: Ignoring the client can escalate the behavior, as individuals with antisocial behavior may act out more to gain attention.

Choice B reason: Introducing him to the newly admitted client and asking him to join the conversation can disrupt the admission process and does not address the client's behavior appropriately.

Choice C reason: Encouraging him to go to the nurse's station and talk with another nurse may be an option, but it does not directly address the client's need for immediate attention.

Choice D reason: Informing him that the nurse is busy and will talk to him later sets clear boundaries and allows the nurse to complete the admission process without disruption.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

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?

The nurse is caring for a client who reports running out of aspirin one week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?