Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is assisting with the care of a client who is receiving a unit of packed RBCs.
Complete the following sentence by using the lists of options. Exhibit 1
The client has manifestations of an
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.
Similar Questions
A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
A. Check the capillary refill every 4 hrs
Check the capillary refill every 4 hrs IncorrectThe nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.
B. Compare the pedal pulses every 4 hrs
Compare the pedal pulses every 4 hrs CORRECTThe nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their lower extremities.
Full Explanation
A. Check the capillary refill every 4 hrs Incorrect
The nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.
B. Compare the pedal pulses every 4 hrs CORRECT
The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their
lower extremities.
A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?
A. The reduced muscle tone relaxed the low muscles
The reduced muscle tone had relaxed the law muscles CORRECTPrior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.
B. "That happens when a person gets close to death
"That happens when a person gets close to death INCORRECTThis automatic response is nontherapeutic and does not address the family member's question
C. "I can apply a chin strap to help hold the mouth closed
"I can apply a chin strap to help hold the mouth closed INCORRECT Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed
Full Explanation
A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.
B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question
C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed
A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?
A. A Provide privacy for the client
Provide privacy for the client CORRECTThe nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment
B. B Expose hair of the body as a
Expose hair of the body as an INCORRECTTo promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected
Full Explanation
A. Provide privacy for the client CORRECT
The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment
B. Expose hair of the body as an INCORRECT
To promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected