BSN HESI 266 BSN 266 Nightingale College Question and answers already passed 2024 A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis ...
BSN HESI 266-- consolidated
A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
a. low back pain and hypotension
When conducting discharge teaching for a client diagnosed with diverticulosis,
which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products
c. Eat a high-fiber diet and increase fluid intake.
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The nurse observes an increased number of blood clots in the drainage tubing
of a client with continuous bladder irrigation following a transurethral resection
of the prostate (TURP). What is the best initial nursing action?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent
c. Increase the flow of the bladder irrigation
A client with lung cancer who wears subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure B. Administer a narcotic antagonist
After falling down the basement steps, a client is brought to the emergency room. X-ray confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity
c. Right foot pale with sluggish capillary refill
The answer indicates a potential problem with the blood circulation in the client's right foot. When a leg cast is applied, it should not interfere with the blood flow to the foot. However, if the foot becomes pale and the capillary refill
is sluggish, it suggests that the blood flow might be compromised. Capillary refill is the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Normal capillary refill time is usually less than 2 seconds. Sluggish or delayed capillary refill can be a sign of peripheral vascular disease, shock, or hypothermia. In this case, it could be due to the cast being too tight, causing a reduction in blood flow to the foot. This is a serious condition that requires immediate intervention by the nurse to
prevent further complications such as tissue necrosis due to lack of oxygen and nutrients. The nurse may need to adjust or remove the cast to restore proper blood flow.
An overweight, young adult who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement?
(Select all that apply.)
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