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 D

Explanation

Choice A rationale

Group discussions can be beneficial for sharing experiences and learning from others, but they do not provide the hands-on, practical experience that is characteristic of the psychomotor learning domain.

Choice B rationale

-answer meetings can be useful for clarifying doubts and enhancing understanding, but they do not offer the opportunity for physical manipulation of objects or execution of procedures, which is central to psychomotor learning.

Choice C rationale

Practice sessions can be an effective method for psychomotor learning as they allow for repeated performance of a skill. However, in the context of teaching adolescents with newly placed ostomies, role play might be more beneficial as it allows for the simulation of real-life scenarios and the practice of problem-solving skills in a safe and controlled environment.

Choice D rationale

Role play is a method that falls under the psychomotor domain of learning. It involves acting out scenarios and provides an opportunity for hands-on practice and learning. In the context of adolescents with newly placed ostomies, role play can help them practice self-care tasks related to ostomy management in a safe and supportive environment.

A. “I could not arrive any sooner. What can I do for you?” B. “We had an emergency on the unit and that was a priority, but now I’m here.”. C. “That must be frustrating for you. How can I help you right now?”

Correct Answer is C

Explanation

Choice A rationale

Saying “I could not arrive any sooner. What can I do for you?” may come off as defensive and does not acknowledge the client’s feelings of frustration.

Choice B rationale

Saying “We had an emergency on the unit and that was a priority, but now I’m here.”. may make the client feel less important and does not acknowledge their feelings of frustration.

Choice C rationale

Saying “That must be frustrating for you. How can I help you right now?” acknowledges the client’s feelings of frustration and offers assistance, which is an appropriate response.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning a teaching session for a group of adolescents who each recently had an ostomy surgically placed. Which of the following methods should the nurse use as a psychomotor approach to learning?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

The client’s chest x-ray shows lung hyperinflation and left upper lobe pneumonia. What is the most likely diagnosis?

A nurse is educating a terminally ill patient about declining resuscitation in a living will.The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

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 home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present. Which observation should the nurse identify as a potential sign of elder abuse?

A nurse is examining a patient’s medication prescription which states, “digoxin 0.25 by mouth daily.”. Which component of the prescription should the nurse confirm with the healthcare provider?

A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

A nurse is about to administer an injection of an opioid medication to a patient. The nurse has drawn 1 mL of the medication from a 2 mL vial.What should the nurse do next?