Question

A patient is receiving a unit of PRBC for a hematocrit of 18, and symptoms of hypovolemia. VS HR 98, BP 89/64, 02 Saturation 95 % on room air, Temp 98.9 F. Fifteen minutes into the transfusion, the patient complains of chills, nausea and headache, vs HR 120, BP 84/60, O2 Sats 94 % on RA and Temp 101.2 F. The most appropriate action for the nurse to perform 7. first would be to Document a possible transfusion reaction b. Stop the transfusion and administer NS Remove and discard the blood and IV tubing d. Verify patient ID and blood type with another professional a C. A 62-vear-old woman tells the nurse "I understand I have Stage II breast cancer and I need 8 to decide on a treatment, but I feel overwhelmed. What do you think I should do"? Which response by the nurse is best? "I would have a lumpectomy, but you need to decide which treatment is best for you. "Tell me what you understand about the treatment options that are available for you." "It would not be appropriate for me to make decisions about your health." d. a. win b b. 6 c. "There is no need to rush to a decision. You have plenty of time to think about nsd bthis." 9. A patient with a diagnosis of endometrial cancer has a total abdominal hysterectomy. Which finding is most important to report to the health care provider? Urine output of 125 mL in the first 8 hours after surgery Decreased bowel sounds in all four abdominal quadrants One-inch area of bloody drainage on the abdominal dressing a 20 C. nsmd. Complaints of abdominal pain at the incision site with coughing buvon h 10. When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? be anivioen l OF Teach the patient how to perform Kegel exercises. b. a. Empty the catheter and document Intake and output. Monitor for presence of pain or bladder spasms. Increase the flow rate of the irrigation if clots are noted. qic. e d. 11. The nurse's aide reports the following VS on a 68-year-old female patient that is post-op day 1 after a left total hip replacement; T 101.1 F, HR 86, RR 22, BP 132/72, 02 Saturation 95% on Room Air. Which intervention would be most appropriate for this patient? Apply 2 L 02 via NC b. Encourage incentive spirometry c. Administer 650 mg Acetaminophen PO Apply ice packs to the groin and axillae a. d. N push 3

Answer 1

Q. No. 7. Answer : is " b ".

That is stop the blood transfusion and administer NS.

Then document the reaction what ever is happened.

because, Normal saline only the compatible solution to use with the blood and blood components. Crysteloid solution may cause the hemolysis of the blood.

So that concentration of the blood will be decreases and the reactions may come down.

So the answer is " b ".

Q. No. 8. Answer : is " b ".

That is Tell me what you understand about the treatment options that are available for you.

Q. No. 10. Answer : is " a "

That is that is teach the patient how to do kegel exercises.

Because it will improve the bladder strength.

So the answer is " a ".

Q. No. 11. Answer : Is " d ".

That is apply ice packs to the groin and axillea region.

Because ice packs will reduce the temperature quickly regulate the hypothalamus regulation.

So the first nursing interventions for temperature is ice pack application, because here the patient is having temperature high.

Remaining all vital signs are good.

So next the drug administration should be done by doctors prescription, if the fever not reduced by cold application also.

So the answer is " d ".