when assessing a male client who is receiving a unit of packed red blood cells prbcs the nurse notes that the infusion was started 30 minutes ago and
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1. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling 'out of breath' but denies any other complaints. What action should the nurse take at this time?

Correct answer: C

Rationale: In this scenario, the client is experiencing symptoms of shortness of breath, which could indicate fluid overload from the PRBC transfusion. By decreasing the intravenous flow rate of the transfusion, the nurse can slow down the rate of blood being infused, potentially alleviating the symptoms of fluid overload and shortness of breath. This intervention can help prevent further complications and promote the client's comfort and safety.

2. When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?

Correct answer: B

Rationale: The priority nursing diagnosis for a client with appendicitis is the 'Risk for infection related to possible rupture of the appendix.' Appendicitis carries a risk of the appendix rupturing, which can lead to peritonitis, a life-threatening condition. Preventing infection through timely intervention and surgery is critical in the care of a client with appendicitis, making this nursing diagnosis the priority.

3. When should the charge nurse intervene based on the observed behavior?

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

4. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.

5. A patient with an anxiety disorder is prescribed alprazolam. What is the primary action of this medication?

Correct answer: D

Rationale: Alprazolam is a benzodiazepine that primarily works by reducing anxiety. It achieves this by enhancing the inhibitory effects of the neurotransmitter GABA in the brain, which leads to a calming effect on the individual. Therefore, the primary action of alprazolam is to decrease anxiety levels rather than increase energy, induce sedation, or elevate mood.

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