Nokea
The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply.
- A. Headache
- B. Tachycardia
- C. Hypertension
- D. Apprehension
- E. Distended neck veins
- F. A sense of impending doom
Correct Answer: A,B,D,F
Rationale: Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life-threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
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A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
- A. Malodorous
- B. Dark in color
- C. Unusually hard
- D. Abnormally small in amount
Correct Answer: A
Rationale: Celiac disease is a disorder characterized by intolerance to gluten, leading to malabsorption and gastrointestinal symptoms. The stools of a child with celiac disease are typically malodorous, bulky, frothy, and pale due to steatorrhea (excess fat in the stool) caused by impaired nutrient absorption. Dark-colored stools, hard stools, or small amounts are not characteristic of celiac disease.
A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse will provide the client with information concerning which condition?
- A. Diabetes insipidus
- B. End-stage renal disease (ESRD)
- C. Chronic urinary tract infection (UTI)
- D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Correct Answer: B
Rationale: In polycystic kidney disease, cystic formation and hypertrophy of the kidneys occur. The most serious complication of polycystic kidney disease is ESRD, which is managed with dialysis or transplant. There is no reliable way to predict who will ultimately progress to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and SIADH secretion are unrelated disorders.
When planning care for a client diagnosed with Cushing's syndrome, the nurse should include which intervention to prevent a common complication of this disorder?
- A. Monitoring glucose levels
- B. Encouraging rigorous exercise
- C. Monitoring epinephrine levels
- D. Encouraging visits from friends
Correct Answer: A
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex or the administration of glucocorticoids in large doses for several weeks or longer. In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Clients experience activity intolerance related to muscle weakness and fatigue; therefore, option 2 is incorrect. Epinephrine levels are not affected. Visitors should be limited because of the client's impaired immune response.
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that began 3 hours ago. What is the priority action?
- A. Obtaining vital signs
- B. Inserting a nasogastric (NG) tube
- C. Asking the client about the precipitating events
- D. Completing an abdominal physical assessment
Correct Answer: A
Rationale: The priority action for the client with GI bleeding is to obtain vital signs to determine whether the client is in shock from blood loss and obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. A complete abdominal physical assessment must be performed but is not the priority. Insertion of an NG tube may be prescribed but is not the priority action.
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.