Question

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Stop the blood transfusion.

Rationale :

🛑The first action when a transfusion reaction is suspected is to stop the blood transfusion immediately to prevent further harm.

⚠️Continuing the transfusion can exacerbate symptoms and worsen the client’s condition.

🩸Once the transfusion is stopped, the nurse should maintain IV access with normal saline and notify the provider.

🧪Sending the blood back to the lab and obtaining a new type and crossmatch are important but must follow the initial action of stopping the transfusion.

📌Core Message

Stopping the transfusion is the essential first step to prevent further exposure and allow for safe implementation of follow-up actions.

Answer 2

Correct Answers:

Cefazolin 1 gram IV every 6 hours.

Rationale :

💉Administering prophylactic antibiotics like cefazolin helps prevent postoperative infections, which can occur quickly after surgery.

⏱️This prescription has time sensitivity as it must be administered at consistent intervals to maintain therapeutic levels.

🦠Preventing infection in the immediate postoperative phase is more critical than interventions like advancing diet or catheterization.

📊Other actions can follow, but initiating infection control takes precedence immediately upon PACU arrival.

📌Core Message

Timely antibiotic administration is the first priority postoperatively to reduce the risk of surgical site infection.

Answer 3

Correct Answers:

The client is competent to sign the consent without impairment of judgment.
The client voluntarily grants permission for the procedure to be done.

Rationale :

📝The nurse’s signature confirms the client is competent, not under influence, and able to make decisions.

👐It also affirms that the client voluntarily signed the form without coercion.

🩺Understanding of the procedure is the responsibility of the surgeon, not the nurse.

📄The nurse does not validate comprehension, only that the form was properly and freely signed.

📌Core Message

The nurse legally confirms client competence and voluntariness when witnessing surgical consent—not procedure understanding.

Answer 4

Correct Answers:

A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).

Rationale :

😷AFB-positive results indicate active tuberculosis, which spreads through airborne particles.

🏥Such clients require negative pressure rooms to prevent airborne transmission.

😮‍💨Staff must wear particulate respirators (e.g., N95) to protect against inhalation of infectious droplets.

🔒These precautions help contain the highly contagious nature of TB and protect other clients and staff.

📌Core Message

Clients with active TB need airborne precautions and negative airflow rooms due to their high contagion risk.

Answer 5

Correct Answers:

Assess the serum potassium level every 4 hours.

Rationale :

🧪Insulin drives potassium into cells, rapidly decreasing serum potassium.

📉This can lead to hypokalemia, which must be detected early through frequent lab monitoring.

⚠️Hypokalemia may cause cardiac arrhythmias, making it more dangerous than mild hyperglycemia.

🔄Monitoring serum potassium levels allows for immediate correction of potential imbalances.

📌Core Message

Frequent potassium level monitoring is crucial when using insulin to treat hyperkalemia due to risk of hypokalemia.

Answer 6

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available

Rationale :

🕓The first step is to document the behavior to create an accurate, objective record.

🔍Next, the manager evaluates for behavioral improvement after intervention.

📅Finally, developing a structured plan, like scheduled breaks, supports a proactive approach to prevent recurrence.

🗂️This order follows a progressive management strategy: record, assess, and then plan.

📌Core Message

Behavior management starts with objective documentation, followed by assessment, and ends with preventive planning.

Answer 7

Correct Answers:

Brain damage with CP is not progressive but does have a variable course.

Rationale :

🧠Cerebral palsy results from non-progressive brain damage that occurred prenatally or during birth.

📈Though the brain injury is static, symptoms may vary with growth and development.

🎯This distinction provides clarity and hope for families concerned about worsening disability.

📚Management focuses on optimizing function and independence, not halting progression.

📌Core Message

Cerebral palsy is a non-progressive disorder, but its effects can change as the child develops.

Answer 8

Correct Answers:

Ask the client about individual care preferences.

Rationale :

🗣️The most respectful way to address religious concerns is to ask the client directly.

💬This approach promotes patient-centered care and ensures the client's unique beliefs are honored.

👂Listening to the client builds trust and promotes cooperation in the care plan.

📖General research or assumptions may miss individual variations within a religion.

📌Core Message

Client-centered religious care begins by asking about personal preferences, not relying on generalized assumptions.

Answer 9

Correct Answers:

1000

Rationale :

📏500 mL over 30 minutes means 16.67 mL/min (500 ÷ 30).

🕒To convert to hourly rate, multiply by 60: 16.67 × 60 = 1000 mL/hr.

📉Setting the pump to 1000 mL/hr ensures accurate delivery over the correct time frame.

💡Always double-check units to ensure precision in IV rate calculations.

📌Core Message

Convert infusion time to an hourly rate using correct math steps for accurate IV administration.

Answer 10

Correct Answers:

Participation of community leaders in planning the program.

Rationale :

🤝Community leaders bring cultural insight and credibility, improving outreach success.

🧭Their involvement promotes community buy-in and helps tailor programs to specific needs.

📣Leaders can help spread the message and increase participation through trusted networks.

📊This approach ensures the program is relevant and acceptable to the target group.

📌Core Message

Engaging community leaders ensures the program is culturally appropriate and gains community support.

1 :
A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

2 :
A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

3 :
After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

4 :
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?

5 :
The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

6 :
An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Available Items

Arrange Your Answers

7 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

8 :
A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

9 :
The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only).

10 :
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

1 : A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

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

3 : After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

4 : 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?

6 : An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Available Items

Arrange Your Answers

7 : The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

8 : A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

9 : The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only).

10 : The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

1 :
A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

2 :
A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

3 :
After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

4 :
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?

6 :
An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

7 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

8 :
A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

9 :
The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only).

10 :
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?