the nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfus
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1. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?

Correct answer: A

Rationale: The correct instruction for the UAP is to continue measuring the client’s vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.

2. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention?

Correct answer: B

Rationale: In a client with a pellet gun injury and a comminuted skull fracture, repeatedly falling asleep while talking with the nurse is a concerning sign. It can indicate increased intracranial pressure or a deteriorating condition, requiring immediate intervention. The other options, such as a throbbing headache (choice A), slow trickle of bright red blood at the entry site (choice C), or reddened and edematous entry site (choice D), while important to monitor, do not directly indicate a need for immediate intervention as much as the client falling asleep repeatedly while talking does.

3. A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.

4. The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Correct answer: C

Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.

5. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which interdisciplinary team member should the nurse consult to assist the client?

Correct answer: A

Rationale: In this scenario, the most appropriate interdisciplinary team member for the nurse to consult is a hospice nurse. Hospice nurses specialize in managing pain and symptom control, which aligns with the client's needs for managing severe chronic pain. While pain specialists (choice B) focus on pain management, in this case, the client specifically requested hospice care for pain management. Consulting a psychologist (choice C) may be beneficial for addressing psychological aspects, but the client's immediate need is pain management. Forming an interdisciplinary team (choice D) is not as specific as consulting a hospice nurse, who has the specialized skills required to address the client's pain effectively.

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