Question 6201)
A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider?
A. Albumin
B. Globulin
C. Thrombin
D. Hemoglobin
Answer: B
Explanation: The gamma-globulin fraction in the plasma is the fraction that includes the antibodies.
Question 6202)
What is the priority nursing intervention for a client during the immediate postoperative period?
A. Monitoring vital signs
B. Observing for hemorrhage
C. Maintaining a patent airway
D. Recording the intake and output
Answer: C
Explanation: Maintenance of a patent airway is always the priority because airway obstruction impedes breathing and may result in death.
Question 6203)
What assessment of the pulse should the nurse identify when a client's on demand pacemaker is functioning effectively?
A. Regular rhythm
B. Palpable at all pulse sites
C. At least at the demand rate
D. Equal to the pacemaker setting
Answer: C
Explanation: On-demand pacing initiates impulses when the client's pulse rate begins to fall below the preset rate. A rate below this indicates malfunction of the pacemaker.
Question 6204)
A nurse identifies that the client understands information about vitamin K when the client states, Vitamin K is:
A. found in a variety of foods, so there is no danger of deficiency.
B. easily absorbed without assistance, so everything eaten is absorbed.
C. rarely found in dietary foods, so a natural deficiency can easily occur.
D. produced in sufficient amounts by intestinal bacteria, so metabolic needs are met.
Answer: D
Explanation: vitamin K is synthesized by intestinal bacteria but is also found in large quantities in green leafy vegetables.
Question 6205)
Nurse Seema is administering 2 unit packed RBC's on a client with a low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood ?
A. Microfusion set
B. Polyvol Pro Burette set.
C. Photofusion set.
D. Tubing with an in-line filter.
Answer: D
Explanation: The in-line filter helps ensure that any particles larger than the size of filter are caught in the filter and are not infused with the client. Option A is incorrect since the tubing that should be used is a macro drip. Option B is used for administration of IV medication infusion. Option C is incorrect since blood does not need any protection from light.
Question 6206)
To verify the age of blood cells in a blood. The nurse will check which of the following?
A. Blood type
B. Blood group
C. Blood identification number
D. Blood expiration date.
Answer: D
Explanation: The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior hanging the blood.
Question 6207) A client has an order to receive a one unit of packed RBC's. The nurse make sure which of the following intravenous solutions to hang with the blood product at the client's bedside?
A. 0.9% Sodium chloride.
B. 5% dextrose in 0.9% sodium chloride.
C. Balanced multiple maintenance solution with 5% dextrose
D. 5% dextrose in 0.45% sodium chloride.
Answer: A
Explanation: 0.9% sodium chloride is a standard solution used to follow infusion of blood products. Option B, C, D : IV solution containing dextrose in water will hemolyze red cells.
Question 6208)
Nurse Jay is caring for a client with an ongoing transfusion of packed RBC's when suddenly the client is having difficulty of breathing skin is flushed and having chills. Which action should nurse Jay take first?
A. Administer oxygen.
B. Place the client on droplight.
C. Check the client's temperature.
D. Stop the transfusion.
Answer: D
Explanation: The client in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion.
Question 6209)
After terminating the transfusion during a reaction. Which action should the nurse immediately be taken next ?
A. Run a solution of 5% dextrose in water.
B. Run normal saline at keep vein open rate.
C. Remove the IV line.
D. Fast drip 200 ml normal saline.
Answer: B
Explanation: The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. Option A: IV solution containing dextrose will hemolyze the red cells. Option C : The nurse will not remove the IV line because then there would be no IV access route. Option D: Doing a fast drip will potential lead to congestion and is not done without the physician order.
Question 6210)
A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the client exhibits which of the following?
A. Less frequent febrile episodes.
B. Increased level of hematocrit.
C. Less episodes of bleeding.
D. Increased level of hemoglobin.
Answer: C
Explanation: Platelet transfusions may be given to prevent bleeding when the platelet count falls down. Option A: decline in the febrile episode will happen after the transfusion of agranulocytes. Option B: An increased level of hemoglobin and hematocrit will happen after the transfusion of red blood cells.
No comments:
Post a Comment