The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above.

Start an IV bolus of lactated Ringer's solution.

Document the blood product transfusion in the client's medical record.

Discard the blood bag in the client's trash can after the transfusion.

Assist with obtaining the first unit of packed RBCs from the blood bank

Monitor the client for the first 15 min of the transfusion.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Abnormal Involuntary Movement Scale. The Abnormal Involuntary Movement Scale (AIMS) is a validated tool specifically designed to assess and identify tardive dyskinesia in clients taking antipsychotic medications. The AIMS evaluates the presence, frequency, and severity of involuntary movements, providing a structured approach for monitoring and documenting these symptoms over time.
B. Brief Psychiatric Rating Scale. The Brief Psychiatric Rating Scale (BPRS) is utilized to assess a range of psychiatric symptoms, including depression, anxiety, and psychosis. However, it does not specifically address the assessment of abnormal involuntary movements associated with tardive dyskinesia. Therefore, while it is useful for general psychiatric evaluation, it is not appropriate for identifying tardive dyskinesia.
C. Patient Health Questionnaire-9. The Patient Health Questionnaire-9 (PHQ-9) is a widely used screening tool for assessing the severity of depression. It focuses on mood-related symptoms and does not evaluate movement disorders or side effects of antipsychotic medications. As such, it is not relevant for identifying tardive dyskinesia.
D. Mental Status Examination. The Mental Status Examination (MSE) provides a comprehensive assessment of a client’s cognitive and emotional state, covering areas such as appearance, behavior, thought processes, and mood. While the MSE is valuable for overall psychiatric evaluation, it does not specifically assess for tardive dyskinesia or abnormal involuntary movements, making it unsuitable for this purpose.

A. Recurring urinary tract infections B. Report of feeling depressed C. Lack of nutritional knowledge D. A recent move to a new city

Correct Answer is D

Explanation

A. Recurring urinary tract infections. Chronic infections act as internal stressors because they arise from within the body, leading to physical discomfort and emotional strain. While they can contribute to stress, they do not originate from an external source, such as environmental or situational factors.
B. Report of feeling depressed. Depression is an internal emotional state rather than an external stressor. Although it can be triggered by external events, depression itself comes from psychological and physiological processes within the individual rather than from outside influences.
C. Lack of nutritional knowledge. Limited knowledge about nutrition is an internal factor affecting decision-making rather than an external stressor. External stressors involve changes in one's environment or circumstances that create pressure, whereas knowledge gaps influence behavior but do not directly impose stress from an outside source.
D. A recent move to a new city. Moving to a new city is an external stressor as it involves environmental change, social adaptation, and logistical challenges. Adjusting to a new home, job, or social network can be overwhelming, increasing stress levels due to uncertainty, unfamiliar surroundings, and the need for adjustment.

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The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

Correct Answer is A

Explanation

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Correct Answer is D

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

A nurse is assisting in the care of a client on a labor and delivery unit. Exhibits Which of the following findings require further evaluation by the nurse? Select all that apply.

A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

A nurse is caring for a client who is at 14 weeks of gestation. Which of the following statements should the nurse identify as the client being emotionally prepared for pregnancy?

The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.