A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Lower back pain and hypotension.

Delayed painful rash with urticaria.

Acute rhinitis and nasal stuffiness.

Arthritic joint changes and chronic pain.

Answer and Explanation

The Correct Answer is A

Lower back pain and hypotension are symptoms of an ABO incompatibility reaction, which is a serious complication of blood transfusion. This reaction occurs when the client receives a blood type that is incompatible with their own. It can cause a rapid and severe response, including back pain, hypotension, fever, and chills. This should be reported immediately to the healthcare provider.

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Correct Answer is A

Explanation

Choice A rationale
Heberden’s nodes are bony swellings that develop at the end joints (distal interphalangeal joints) of fingers, particularly the fingers closest to the nails. They are a characteristic feature of osteoarthritis, a degenerative joint disease. Osteoarthritis causes the protective cartilage in the joints to wear down over time, leading to the development of these bony growths, which can be painful and limit joint movement. Therefore, discussing strategies for managing chronic pain with the patient is the most appropriate action for the nurse to take.
Choice B rationale
While checking the patient’s radial pulses and capillary refill time is a part of a comprehensive physical assessment, it is not directly related to the management of Heberden’s nodes or osteoarthritis.
Choice C rationale
Although Heberden’s nodes are a sign of osteoarthritis, they are not typically an emergency that requires immediate notification of the healthcare provider. They are a common finding in individuals with osteoarthritis and are usually managed with conservative measures such as pain management and physical therapy.
Choice D rationale
Reviewing the patient’s dietary intake of high-protein foods is not directly related to the management of Heberden’s nodes or osteoarthritis. While a balanced diet is important for overall health, it does not specifically address the pain and limited joint movement associated with Heberden’s nodes.

A. The patient exclusively consumes lactose-free dairy products. B. The patient meticulously cleans and peels all fresh fruits and vegetables. C. The patient enjoys fat-free yogurt as an occasional snack. D. The patient has eliminated grains from their diet.

Correct Answer is C

Explanation

Choice A rationale
Exclusively consuming lactose-free dairy products is not a specific characteristic of the DASH diet. While the DASH diet recommends low-fat or fat-free dairy products, it does not specifically require them to be lactose-free.
Choice B rationale
Meticulously cleaning and peeling all fresh fruits and vegetables is a good practice for food safety, but it is not specific to the DASH diet.
Choice C rationale
Enjoying fat-free yogurt as an occasional snack aligns with the DASH diet’s emphasis on low-fat dairy products.
Choice D rationale
Eliminating grains from the diet is not recommended in the DASH diet. On the contrary, the DASH diet encourages the consumption of whole grains.

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A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful. What should the nurse do?

Correct Answer is A

Explanation

The nurse is assessing a patient’s understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?

Correct Answer is C

Explanation

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