Nokea
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
You may also like to solve these questions
Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?
- A. Creatinine
- B. Sodium
- C. Calcium
- D. Potassium
Correct Answer: A
Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) involves logical, coherent thinking about concrete events, not abstract concepts. Perspective-taking improves but is secondary to logical thought.
A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?
- A. Obtaining blood pressures every two hours
- B. Administering pain medication every three hours as ordered
- C. Monitoring arterial blood gas results
- D. Administering IV fluids at ordered rate of 200 mL/hr
Correct Answer: D
Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (A), pain medication (B), and ABGs (C) are supportive but less directly preventive.
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:
- A. Gravida 3 para 1
- B. Gravida 3 para 2
- C. Gravida 2 para 1
- D. Gravida 2 para 2
Correct Answer: B
Rationale: Gravida=3 (current pregnancy), Para=2 (two births after 20 weeks).
The physician has ordered a liver panel for a client with suspected hepatitis. Which laboratory result is most indicative of liver damage?
- A. Elevated ALT
- B. Decreased hemoglobin
- C. Elevated sodium
- D. Decreased potassium
Correct Answer: A
Rationale: Elevated alanine aminotransferase (ALT) is specific to liver damage, as it is released when hepatocytes are injured, common in hepatitis. Hemoglobin, sodium, and potassium are not directly indicative of liver function.