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.

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Correct Answer is C

Explanation

A) Strains are associated with fractured bone that are tearing blood vessels:
Strains refer to injuries of muscles or tendons due to overuse, overstretching, or tearing. A strain does not typically involve fractured bones or tearing blood vessels. Sprains, on the other hand, involve ligaments, not muscles or tendons, and may or may not involve fractures or tearing of blood vessels.

B) "A strain should be treated with heat in the first 24 hours then ice after:
. The general recommendation for the initial treatment of a strain (and sprain) is rest, ice, compression, and elevation (R.I.C.E.) within the first 24-48 hours. Ice should be applied during this period to reduce swelling and inflammation, not heat. Heat may be used after the first 48 hours to promote healing and reduce muscle stiffness, but it should not be used during the acute phase of the injury.

C) A sprain involves stretching or tearing or tearing of ligaments at a joint:
This is the correct statement. A sprain is an injury to a ligament, which is the tissue connecting bones to other bones. It is typically caused by stretching, overextension, or tearing of the ligament, often resulting from a sudden or awkward movement at a joint. Sprains commonly occur at areas such as the ankle, knee, and wrist.

D) A sprain involves tearing of a muscle body or tendon:
. A sprain involves damage to a ligament, not a muscle or tendon. Damage to muscles or tendons is classified as a strain, not a sprain. Strains refer to overuse or tearing of muscle fibers or tendons, not ligaments.

A. Hemoglobin and hematocrit count B. CD4+ count cell C. Western blot D. Enzyme-linked immunosorbent assay (ELISA)

Correct Answer is B

Explanation

A. Hemoglobin and hematocrit count:
Hemoglobin and hematocrit levels are useful in assessing overall blood volume and oxygen-carrying capacity. While these tests can help identify anemia or other hematologic abnormalities that might occur in HIV-infected individuals, they do not provide specific information regarding the stage of HIV infection or the immune function. Therefore, they are not the most helpful for determining the stage of the disease.

B. CD4+ count cell:
The CD4+ count is the most important laboratory test for assessing the progression of HIV. CD4+ T cells are critical components of the immune system, and their count reflects the level of immune suppression in the body. As HIV progresses, the CD4+ count decreases, making the individual more vulnerable to opportunistic infections. A low CD4+ count (typically below 200 cells/mm³) indicates that the individual has progressed to acquired immunodeficiency syndrome (AIDS). Therefore, the CD4+ count provides the most direct insight into the stage of HIV infection.

C. Western blot:
The Western blot test is used to confirm an HIV diagnosis after an initial positive screening test, such as the ELISA. It is not used to assess the stage of the disease. While it helps to confirm the presence of HIV antibodies, it does not provide information about immune function or the progression of the disease.

D. Enzyme-linked immunosorbent assay (ELISA):
The ELISA is a screening test used to detect antibodies against HIV. If the ELISA test is positive, it is usually followed by a confirmatory test (such as the Western blot). While ELISA is important for diagnosing HIV infection, it does not provide information about the current stage or progression of the disease. Therefore, it is not the most helpful test for assessing the stage of HIV infection once the diagnosis is established.

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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

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