Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
A. Administer the transfusion through a 25-gauge saline lock.
Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B. Administer the plasma immediately after thawing.
Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C. Transfuse the plasma over 4 hr.
Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D. Hold the transfusion if the client is actively bleeding.
Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Med Surg 2023 Proctored Exam. Take the full exam now
Full Explanation
A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.
Similar Questions
A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
A. Instruct the client to sit on a rubber ring when seated in a chair.
Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B. Raise the head of the client's bed to a 90° angle.
Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C. Use moisturizing lotion while massaging the client's bony prominences.
Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D. Place pillows between the client's knees when in a side-lying position.
Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.
Full Explanation
A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.
A nurse is caring for a client who weighs 190 lb and is receiving total parenteral nutrition. If the RDA of protein is 0.8 g/kg of body weight, how many grams of protein should the client receive daily? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the daily protein requirement for the client, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds.
The client's weight in kilograms is 190 lb divided by 2.2, which equals approximately
86.36 kg.
Then, multiply the weight in kilograms by the recommended dietary allowance (RDA) of protein, which is 0.8 g/kg. So, 86.36 kg multiplied by 0.8 g/kg equals about
69.09 g. Rounding to the nearest whole number, the client should receive 69 grams of protein daily.
A nurse is admitting a client who reports tightness in their chest that radiates to left arm.
The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.
A. Blood glucose level
The client’s blood glucose in this scenario is within the normal range.
B. Bowel sounds
The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C. Blood pressure
The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D. Pain level
The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E. Electrocardiogram findings
The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F. Lung sounds
The lungs are clear on auscultation of all the lobes which is normal.
G. Troponin T level
The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
Full Explanation
A) The client’s blood glucose in this scenario is within the normal range.
B) The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F) The lungs are clear on auscultation of all the lobes which is normal.
G) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.