Nokea
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply.
- A. If a client should develop crackles in their lung fields, it is a sign of a hemolytic reaction.
- B. Transfusion-related graft versus host disease most commonly occurs in immuno-suppressed individuals.
- C. Transfusion-associated circulatory overload (TACO) is more common in clients with renal failure.
- D. It is important to ask the client about history of previous blood transfusions.
- E. Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion.
Correct Answer: A,E
Rationale: Crackles in the lung fields indicate transfusion-associated circulatory overload (TACO), not a hemolytic reaction, which typically presents with fever, chills, and hemoglobinuria. Pre-medication with diphenhydramine and acetaminophen is not always required, only when prescribed for clients with a history of allergic reactions. The other statements are correct: graft versus host disease is common in immunosuppressed clients, TACO is more likely in renal failure, and transfusion history is important.
You may also like to solve these questions
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and drinks one to two beers with her husband after work almost every day. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What combination of behavioral changes should the nurse instruct this client to make first?
- A. Decrease fat in the diet, decrease alcohol consumption, and use sunscreen every day.
- B. Decrease intake of salt-cured food, lose weight, and stop smoking.
- C. Stop drinking beer, decrease fiber in the diet, and use sun protection.
- D. Stop smoking, use sun protection, and lose weight.
Correct Answer: D
Rationale: Stopping smoking, using sun protection, and losing weight address the most critical modifiable risk factors for this client, given her smoking history, prior skin cancer, and obesity, which are linked to multiple cancers.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client?
- A. Ask the client's spouse to supervise the daily administration of the medications.
- B. Visit the client weekly to ask him whether he is taking his medications regularly.
- C. Notify the physician of the client's noncompliance and request a different prescription.
- D. Remind the client that tuberculosis can be fatal if it is not treated promptly.
Correct Answer: A
Rationale: Having a spouse supervise medication administration ensures adherence, critical for tuberculosis treatment. Weekly visits are insufficient. Changing prescriptions doesn't address noncompliance. Fear-based reminders are less effective than direct support.