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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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Emotional lability refers to rapid and intense mood swings, which are a common characteristic of borderline personality disorder. Individuals with this disorder may experience extreme shifts in emotions, such as sudden anger, sadness, or elation, often triggered by minor events.
Fear of abandonment is another core feature of borderline personality disorder. Individuals may go to great lengths to avoid real or perceived rejection, leading to unstable relationships and intense emotional reactions. This fear can manifest as extreme clinginess, hostility, or impulsivity when they believe they are being neglected or left alone.
Increased heart rate and elevated body temperature are physiological responses that can occur in various medical conditions but are not specific to borderline personality disorder. Tactile hallucinations, which involve the sensation of touch without a physical stimulus, are more commonly associated with substance use disorders or psychotic disorders rather than borderline personality disorder.

A. Empty the collection chamber every 8 hr. B. Place the client in a supine position. C. Ensure the device is kept below the level of the client's chest. D. Clamp the chest tube every 4 hr.

Correct Answer is C

Explanation

A. "Empty the collection chamber every 8 hr." The collection chamber should not be emptied on a regular schedule like every 8 hours. It should be emptied when it becomes full or according to facility policy. Regular monitoring of the chamber is essential to assess drainage and ensure it does not exceed capacity.
B. "Place the client in a supine position." The client should not be placed in a supine position when a chest tube is in place for a pneumothorax. The optimal position is typically sitting up or at least semi-Fowler’s position to facilitate lung expansion and drainage.
C. "Ensure the device is kept below the level of the client's chest." Keeping the chest tube drainage system below the level of the client’s chest is crucial for proper drainage and to prevent backflow of fluid or air. This position facilitates gravity drainage and helps maintain the effectiveness of the suction.
D. "Clamp the chest tube every 4 hr." Clamping the chest tube is generally not recommended unless specifically ordered by a healthcare provider. Clamping can lead to increased pressure in the pleural space and risk of tension pneumothorax. The nurse should avoid clamping unless there is a clear and appropriate reason to do so.

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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 assisting with the care of a client. Exhibits The nurse is collecting data from the client. Drag words from the choices below to fill in each blank in the following sentence. The nurse should identify that dropdownand dropdownindicate manifestations of borderline personality disorder.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdownand thendropdown

A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

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.