A client suffered a hemolytic transfusion reaction after being given packed red blood cells with an incompatible blood type. The client recovered.
The nurse should recognize that this scenario best describes which of the following types of safety events?
Sentinel event.
Never event.
Minor injury.
Root Cause Analysis.
The Correct Answer is A
Choice A rationale
A sentinel event is an unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a client, not related to the natural course of the client's illness. A hemolytic transfusion reaction with an incompatible blood type, leading to client recovery, perfectly fits this definition due to its severity and preventability.
Choice B rationale
A never event is a medical error that is clearly identifiable, preventable, and serious in its consequences for the client. While a hemolytic transfusion reaction is preventable, the term "never event" specifically refers to a list of events identified by organizations like the National Quality Forum that should never occur. While closely related, "sentinel event" emphasizes the severe outcome.
Choice C rationale
A minor injury refers to an injury that is not severe or life-threatening and does not result in significant long-term harm or disability. A hemolytic transfusion reaction is a severe and potentially life-threatening immunological response to incompatible blood, making "minor injury" an inaccurate description of the event's severity and implications.
Choice D rationale
Root Cause Analysis (RCA) is a systematic process for identifying the underlying causes of problems or incidents in a healthcare setting. While an RCA would be conducted following a sentinel event like a hemolytic transfusion reaction to prevent recurrence, RCA itself is a process, not a type of safety event. The event itself is the sentinel event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A weight gain of 2 pounds in a week, while notable, may not always be immediately alarming in a client with heart failure taking a diuretic, as fluid retention can fluctuate. However, it warrants close monitoring and further assessment to determine if it signifies impending decompensation, as it is less acute than other choices.
Choice B rationale
Increased urination is an expected and desired effect of diuretic therapy in heart failure. Diuretics work by promoting the excretion of excess fluid and sodium from the body through the kidneys, leading to increased urine output. This finding indicates that the medication is effectively working to reduce fluid overload.
Choice C rationale
A weight gain of 3 pounds in 24 hours in a client with heart failure is a significant and rapid accumulation of fluid. This acute weight gain strongly suggests fluid overload and indicates that the diuretic therapy may be insufficient or that the client's heart failure is worsening, requiring immediate medical attention to prevent pulmonary edema.
Choice D rationale
Dyspnea on exertion, or shortness of breath with activity, is a common symptom of heart failure progression or worsening fluid overload. As fluid accumulates in the lungs, it impairs gas exchange, leading to exertional dyspnea. This finding indicates a need for immediate intervention to optimize fluid balance and improve respiratory function.
Correct Answer is B
Explanation
Choice A rationale
While social distancing can help prevent transmission of various pathogens, for active tuberculosis, the primary focus for discharge teaching is adherence to the medication regimen. Social distancing alone is not sufficient to eradicate the mycobacterium from the individual, which requires comprehensive antimicrobial therapy.
Choice B rationale
Adherence to the medication regimen is paramount for clients with active tuberculosis. This ensures the complete eradication of Mycobacterium tuberculosis, preventing drug resistance and recurrence. Non-adherence can lead to treatment failure, prolonged infectivity, and the development of multi-drug resistant strains, making future treatment more challenging.
Choice C rationale
Wearing a mask around family members is a crucial measure to prevent the airborne transmission of Mycobacterium tuberculosis in the home environment. The mask acts as a physical barrier, containing respiratory droplets expelled during coughing, sneezing, or talking, thus reducing the risk of infection for close contacts.
Choice D rationale
While adequate hydration is generally beneficial for overall health, it is not a specific priority for discharge teaching in clients with active tuberculosis compared to medication adherence. Hydration does not directly impact the elimination of the Mycobacterium tuberculosis from the body or prevent its transmission.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.