Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
While receiving a unit of packed RBCs, the patient develops chills. itching hives. and a temperature of 1022 F (39.0 C). What is the priority action for the nurse to take?
A. Stop the transfusion and disconnect the blood tubing.
The priority action is to stop the transfusion immediately and disconnect the blood tubing to prevent further infusion of the possibly incompatible blood product. The nurse should then maintain IV access with normal saline using new tubing.
B. Slow down the rate of the transfusion.
Slowing the transfusion is inappropriate; any signs of a transfusion reaction require stopping it immediately.
C. Notify the health care provider and the blood bank.
The provider and blood bank should be notified, but stopping the transfusion is the priority.
D. Administer intramuscular epinephrine.
Epinephrine is used for anaphylactic reactions with airway involvement. The nurse should assess further before administering it.
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Full Explanation
A. The priority action is to stop the transfusion immediately and disconnect the blood tubing to prevent further infusion of the possibly incompatible blood product. The nurse should then maintain IV access with normal saline using new tubing.
B. Slowing the transfusion is inappropriate; any signs of a transfusion reaction require stopping it immediately.
C. The provider and blood bank should be notified, but stopping the transfusion is the priority.
D. Epinephrine is used for anaphylactic reactions with airway involvement. The nurse should assess further before administering it.
Similar Questions
should assess further before administering it.
A. 23. Which patent statement to the nurse indicates that the patient understands self-care for pernicious anemia?
Vitamin B6 is important for overall health but does not treat pernicious anemia.
B. “I should increase intake foods rich in vitamin B6.”
Increasing dietary intake of B12-rich foods like red meat and liver is ineffective since the body cannot absorb B12 due to intrinsic factor deficiency.
C. “I need to Start eating more red meat and liver.”
While some anemias affect bone marrow function, pernicious anemia is not associated with increased infection and bleeding risk.
D. “This condition with my bone marrow also increases my risk of infection and bleeding.”
Pernicious anemia is caused by a lack of intrinsic factor, which is necessary for vitamin B12 absorption. Since dietary B12 cannot be absorbed, lifelong vitamin B12 injections are required.
E. “I will require periodic vitamin B12 injections."
Full Explanation
A. Vitamin B6 is important for overall health but does not treat pernicious anemia.
B. Increasing dietary intake of B12-rich foods like red meat and liver is ineffective since the body cannot absorb B12 due to intrinsic factor deficiency.
C. While some anemias affect bone marrow function, pernicious anemia is not associated with increased infection and bleeding risk.
D. Pernicious anemia is caused by a lack of intrinsic factor, which is necessary for vitamin B12 absorption. Since dietary B12 cannot be absorbed, lifelong vitamin B12 injections are required.
Eight years after beginning antiretroviral therapy (ART), a patient with human immunodeficiency virus infection has a CD4+ cell count of 81 cell/L and an "undetectable" viral load. Which intervention would the nurse include in the plan of care?
A. Advise the client that they are currently at high risk for transmitting the disease.
An "undetectable" viral load means the risk of HIV transmission is significantly reduced ("Undetectable = Untransmittable" or U=U), though precautions should still be followed.
B. Encourage adequate nutrition. exercise, sleep. and standard infection prevention practices.
Clients with a low CD4+ count (<200 cells/µL) are at increased risk for opportunistic infections. Encouraging a healthy lifestyle and infection prevention helps maintain immune function.
C. Encourage antibiotic prophylaxis to keep viral load from elevating,
Antibiotic prophylaxis is considered for clients with CD4+ counts <200 cells/µL, but it does not prevent viral load elevation.
D. Inform the client that they have been cured of their condition and will no longer require treatment.
There is no cure for HIV; lifelong ART is required to maintain viral suppression.
Full Explanation
A. An "undetectable" viral load means the risk of HIV transmission is significantly reduced ("Undetectable = Untransmittable" or U=U), though precautions should still be followed.
B. Clients with a low CD4+ count (<200 cells/µL) are at increased risk for opportunistic infections. Encouraging a healthy lifestyle and infection prevention helps maintain immune function.
C. Antibiotic prophylaxis is considered for clients with CD4+ counts <200 cells/µL, but it does not prevent viral load elevation.
D. There is no cure for HIV; lifelong ART is required to maintain viral suppression.
The nurse is providing discharge teaching to a client newly diagnosed With HIV. Which of the following statements would the nurse include in the teaching to reduce the risk of opportunistic infections? Select all that apply.
A. “Wash dishes in hot water with antimicrobial soap."
Washing dishes in hot water with antimicrobial soap helps prevent foodborne infections.
B. "Perform frequent hand and Oral hygiene."
Frequent hand and oral hygiene reduce the risk of bacterial and fungal infections.
C. "Have at least one person sitting between you and any sick family members at the dinner table.”
Simply sitting farther away from sick individuals is not sufficient; avoiding direct contact and ensuring proper hand hygiene is more effective.
D. “Wear gloves while cleaning the cat's litter box.”
Wearing gloves while cleaning the litter box prevents toxoplasmosis, an opportunistic infection common in immunocompromised clients.
E. “Be sure to rinse fresh fruits and vegetables before eating.”
Rinsing fresh produce reduces the risk of foodborne illnesses.
Full Explanation
A. Washing dishes in hot water with antimicrobial soap helps prevent foodborne infections.
B. Frequent hand and oral hygiene reduce the risk of bacterial and fungal infections.
C. Simply sitting farther away from sick individuals is not sufficient; avoiding direct contact and ensuring proper hand hygiene is more effective.
D. Wearing gloves while cleaning the litter box prevents toxoplasmosis, an opportunistic infection common in immunocompromised clients.
E. Rinsing fresh produce reduces the risk of foodborne illnesses.