A nurse has initiated the infusion of packed RBCs through an 18-gauge peripheral IV to be administered over 2 hours. The client is experiencing symptoms of itching and anxiety, and presents with a flushed face and hives.
Complete the following sentence: “The client’s condition is indicative of _.”.

An allergic reaction

Normal side effects of the procedure

Anxiety disorder

Hypersensitivity to the IV gauge material .

Answer and Explanation

The Correct Answer is A

Choice A rationale

The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.

Choice B rationale

While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.

Choice C rationale

Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.

Choice D rationale

Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.

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Correct Answer is C

Explanation

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

A. Insert the needle at a 15-degree angle. B. Aspirate for blood return before administration. C. Administer the medication into the abdomen. D. Massage the site after the injection.

Correct Answer is C

Explanation

Choice A rationale

Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.

Choice B rationale

Aspirating for blood return before administration is not necessary when administering heparin.

Choice C rationale

Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.

Choice D rationale

Massaging the site after the injection is not recommended as it can cause bruising.

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Naxlex Comprehensive Predictor Exams

A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Correct Answer is C

Explanation

A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which response by the nurse is appropriate?

A nurse is providing discharge instructions to a patient who will be using a walker.Which of the following statements by the patient indicates that the teaching has been effective?

A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?

A nurse is caring for a client who has COPD.The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.Which three findings require follow-up?

A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

A nurse is educating a client who is under protective isolation precautions. Which statement from the client indicates they have understood the teaching?