A client is receiving a blood transfusion, The nurse observes that the client is experiencing flank and lower back pain. Which of the following orders does the nurse anticipate receiving?

Intramuscular epinephrine

Intravenous corticosteroids

High volume IV fluids

PO diphenhydramine

Answer and Explanation

The Correct Answer is C

A. Intramuscular epinephrine:
Intramuscular epinephrine is typically used in cases of anaphylactic reactions, which present with symptoms such as difficulty breathing, swelling, hives, and hypotension. Flank and lower back pain are not typical signs of an anaphylactic reaction during a blood transfusion. Instead, flank pain may suggest a hemolytic reaction, which involves the destruction of red blood cells, not an allergic or anaphylactic response. Thus, epinephrine would not be the first-line treatment for this situation.

B. Intravenous corticosteroids:
Intravenous corticosteroids are often used for inflammatory reactions, such as in cases of autoimmune diseases or severe allergic reactions. While corticosteroids might be used for certain types of transfusion reactions, they are not the primary treatment for hemolytic reactions (which could cause flank and lower back pain). The primary goal in a transfusion reaction with flank pain is to manage potential hemolysis and prevent kidney damage, which would be addressed through hydration and other supportive measures.

C. High volume IV fluids:
High-volume IV fluids are the most appropriate immediate intervention for a client who is experiencing flank and lower back pain during a blood transfusion, which are signs of a potential hemolytic reaction. Hemolysis, or the breakdown of red blood cells, can lead to kidney injury, so increasing fluid volume helps flush the kidneys, promote diuresis, and reduce the risk of kidney damage. The fluids also help to dilute any hemoglobin that is released into the bloodstream, supporting the kidneys' ability to filter it out. This is the priority intervention in this scenario.

D. PO diphenhydramine:
Oral diphenhydramine is used for allergic reactions, such as mild reactions involving itching, rashes, or hives, but it is not appropriate for managing more severe transfusion reactions, such as hemolytic reactions, that cause flank and lower back pain. Diphenhydramine would not address the underlying issue of potential hemolysis and kidney injury. Therefore, it is not the correct intervention for this situation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. The client should report to an urgent care for potential hypokalemia:
While ACE inhibitors like Captopril can increase potassium levels (hyperkalemia) due to their effects on the renin-angiotensin-aldosterone system, they are not typically associated with hypokalemia. The client's complaint of a dry cough is a well-known side effect of ACE inhibitors, not an indication of low potassium levels. Therefore, the recommendation to seek urgent care for hypokalemia is not appropriate in this case.

B. The client should immediately use an epinephrine auto-injector (Epi-Pen) and call 9-1-1:
The use of an epinephrine auto-injector is specifically indicated for severe allergic reactions (anaphylaxis), which typically present with symptoms such as difficulty breathing, swelling of the throat, or anaphylactic shock. A chronic dry cough associated with the use of Captopril is not indicative of an allergic reaction, but rather a known adverse effect of ACE inhibitors. Therefore, this response is inappropriate for the situation described.

C. The client should contact their provider, who may switch them to a different medication:
A chronic dry cough is a common side effect of ACE inhibitors like Captopril, occurring in some individuals due to the accumulation of bradykinin. If the cough is bothersome, the best course of action is for the client to contact their healthcare provider. The provider may consider switching the patient to an angiotensin II receptor blocker (ARB), which does not typically cause this side effect. This is the most appropriate and safe action.

D. The client should stop taking the Lisinopril immediately:
Lisinopril is an ACE inhibitor, similar to Captopril, and shares the same potential side effects, including a chronic dry cough. However, the client should not stop taking their medication without consulting their healthcare provider. Discontinuing the medication abruptly can result in uncontrolled hypertension and other risks. The correct course of action is to contact the provider to discuss possible alternatives, not to stop the medication independently.

A. Troponins I & T B. Creatine Kinase C. C Reactive Protein D. Myoglobin

Correct Answer is A

Explanation

A. Troponins I & T:
Troponins I and T are the most specific biomarkers for myocardial damage. These proteins are released into the bloodstream when the heart muscle is injured, such as during a myocardial infarction (MI). Troponins remain elevated for a prolonged period (typically up to 1-2 weeks) after myocardial injury, making them highly sensitive for detecting both acute and recent myocardial damage. Because of their high specificity for heart muscle, they are considered the gold standard for diagnosing acute myocardial infarction.

B. Creatine Kinase:
Creatine kinase (CK) is an enzyme found in the heart, brain, and skeletal muscle. While CK-MB (the heart-specific isoenzyme) can be elevated in cases of myocardial damage, it is less specific than troponins because it can also be elevated due to skeletal muscle injury or other conditions. CK-MB levels rise more rapidly than troponins but return to baseline within 48-72 hours, making it less useful for detecting myocardial damage over a longer period.

C. C-Reactive Protein (CRP):
C-Reactive Protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation or tissue injury. While CRP levels can be elevated in various inflammatory conditions, including atherosclerosis, it is not specific to myocardial damage. Elevated CRP is associated with increased risk for cardiovascular events but does not provide specific information about acute myocardial injury, making it less helpful for diagnosing myocardial infarction.

D. Myoglobin:
Myoglobin is an oxygen-binding protein found in both skeletal and cardiac muscle. While it is an early marker that rises rapidly after muscle injury, it lacks specificity for myocardial damage because it is also released from skeletal muscle. Myoglobin levels peak quickly (within 1-4 hours of injury) and return to baseline within 24 hours, so it is not as useful for diagnosing a myocardial infarction or monitoring long-term cardiac injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is receiving a blood transfusion, The nurse observes that the client is experiencing flank and lower back pain. Which of the following orders does the nurse anticipate receiving?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of hypertension who was prescribed Captopril complains of a chronic dry cough for the past several weeks. Which of the following actions should the nurse recommend?

Correct Answer is C

Explanation

The nurse is caring for client who presented to the emergency department for chest pain. The nurse knows that which of the following laboratory tests is most specific for myocardial damage?

Correct Answer is A

Explanation

Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?

The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

The parents of a pediatric client describe occasional episodes where the client seems to experience a temporary loss of awareness and a blank stare. The nurse suspects which of the following disorders?

Which action should the nurse take first when discovering a fire in the client's bathroom trash can?

The nurse is preparing to administer a shot of vitamin B12 to a client with low hemoglobin. The nurse knows that this medication is most indicative of which type of anemia?

The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?