The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Stay with the client for the first 15 min of the transfusion.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

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

Obtain the first unit of packed RBCs from the blood bank.

Start an IV bolus of lactated Ringer's solution.

Answer and Explanation

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

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomachs.
Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.

A. “I can lift objects that are less than 10 pounds.” B. “I can resume activities, such as sewing.” C. “I can go jogging after 2 weeks.” D. “I should bend at the waist when putting on my shoes.”

Correct Answer is A

Explanation

This statement indicates that the client understands the need to avoid activities that can increase intraocular pressure, such as lifting heavy objects, bending over, coughing, or straining. An increase in intraocular pressure can cause complications such as bleeding, inflammation, or recurrent detachment of the retina.

Choice B is wrong because sewing is a near-vision activity that can cause eye strain and fatigue. The client should avoid near-vision activities for at least two weeks after surgery.

Choice C is wrong because jogging is a vigorous exercise that can cause jarring movements and increase blood pressure. The client should avoid vigorous exercise for at least six weeks after surgery.

Choice D is wrong because bending at the waist can increase intraocular pressure and compromise the healing of the retina. The client should avoid bending at the waist for at least two weeks after surgery.

The retina is the light-sensitive layer of tissue that lines the back of the eye.

It converts light into electrical signals that are sent to the brain through the optic nerve.

A detached retina occurs when the retina separates from its underlying tissue due to a tear, hole, or break in the retina.

This can cause vision loss or blindness if not treated promptly.

The most common treatment for a detached retina is a surgery called vitrectomy. It typically involves three main steps:

The vitreous gel inside the eye must be removed.
A gas bubble is injected into the eye to hold the retina against its underlying tissue while allowing it to heal.
Laser or cryotherapy creates scar tissue that helps reattach the retina.

The recovery time after retinal detachment surgery varies depending on the type and extent of the detachment, the type of surgery, and the individual healing process of the client.

Some general guidelines to follow after retinal detachment surgery are:

Rest your eyes for at least two weeks after the surgery.
Wear sunglasses when outdoors, as bright light may cause discomfort and strain on the eye that has been operated upon.
If your doctor recommends, use artificial tears every few hours to keep moisture in the eye and lubricate it correctly.
Take your medicines as directed by your doctor.
You may use ice on your eye to reduce swelling

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The nurse reviews the entries in the medical record. Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings is an indication that the medication has been effective

A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

A nurse in an emergency department is caring for a client Exhibits The nurse is preparing to discharge the client. Which of the following statements by the client indicate an understanding of the discharge teaching? Select all that apply.

The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.