Strategy: Determine the outcome of each answer. Is it desired?
1) CORRECT— should be sent to lab for hemoglobin determination; symptoms of hemolytic reaction include nausea, vomiting, pain in lower back, hypotension, increase in pulse rate, decrease in urinary output, hematuria
2) should restart normal saline; stop the blood, supportive care: oxygen, Benadryl, airway management
3) container should be returned to lab
4) should be discontinued due to hemolytic reaction; draw blood sample for plasma, hemoglobin culture, and retyping
The nurse performs dietary teaching with a client who has hepatitis B. Which of the following menus, if selected by the client, is BEST?
1. Hamburger, french fries, a dill pickle, and malted milk.
2. Lean roast beef, baked potato, green beans, and coffee.
3. Bacon, eggs, toast with butter, and milk.
4. Biscuits with sausage, gravy, and buttered grits, and orange juice.
Strategy: Determine outcome of each answer. Is it desired?
1) separation anxiety indicates normal development; fear of strangers begins at 7 months, peaks at 8 months
2) no indication of abuse; normal development
3) is normal growth and development, question asks for best response; phases-protests, cries/screams for parents and is inconsolable by others; despair, cry ends but is less active, not interested in food or play; denial, appears adjusted, appears interested in environment, ignores parents when they return
4) CORRECT— exhibiting separation anxiety; reassure child by offering favorite blanket or toy, talk to infant when leaving the room, and allow infant to hear parent's voice on telephone