Nokea
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
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A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should sleep flat in bed at night.
- B. I should eat three large meals a day.
- C. I should avoid drinking decaffeinated coffee.
- D. I should remain upright after eating.
Correct Answer: D
Rationale: Remaining upright after eating reduces acid reflux by preventing stomach contents from flowing back into the esophagus, aiding in GERD management.
A nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. Which of the following instructions should the nurse include?
- A. Avoid eating after midnight before the procedure.
- B. Lie flat for 4 to 6 hours after the procedure.
- C. Expect general anesthesia during the procedure.
- D. Avoid drinking fluids for 12 hours before the procedure.
Correct Answer: B
Rationale: Lying flat for 4 to 6 hours after a lumbar puncture prevents cerebrospinal fluid leakage and reduces headache risk.
A nurse is caring for a client who has a new prescription for bupropion. Which of the following adverse effects should the nurse monitor for?
- A. Insomnia
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Bupropion, an antidepressant, can cause insomnia due to its stimulatory effect on the central nervous system.
A nurse is caring for a client who has a new prescription for gabapentin. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Gabapentin commonly causes drowsiness, which can affect the client's alertness and safety.
A nurse is reinforcing teaching with a client who has a new prescription for a medicated foot powder. Which of the following instructions should the nurse include?
- A. Apply the powder to wet feet.
- B. Use the powder twice a week.
- C. Apply a thick layer between the toes.
- D. Wear socks after applying the powder.
Correct Answer: D
Rationale: Wearing socks after applying medicated foot powder helps keep the medication in place and prevents spreading.