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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.
Choice B rationale
The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.
Choice C rationale
The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.
Choice D rationale
The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.
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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