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A nurse is assessing a patient who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

Nystagmus.

Bradycardia.

Chills.

Hypothermia.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Nystagmus, which is involuntary eye movement, is not a common adverse effect of a platelet transfusion.

Choice B rationale

Bradycardia, or a slow heart rate, is not typically associated with platelet transfusions.

Choice C rationale

Chills can be an adverse effect of a platelet transfusion. This could be a sign of a reaction to the transfusion, such as an allergic reaction or a febrile non-hemolytic transfusion reaction.

Choice D rationale

Hypothermia is not a common adverse effect of a platelet transfusion.

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Correct Answer is C

Explanation

Choice A rationale

Streptococcal pharyngitis, also known as strep throat, is a bacterial infection that causes inflammation and pain in the throat. This condition is spread through respiratory droplets, not through the air, and does not require airborne precautions.

Choice B rationale

Scabies is caused by a mite infestation, not an airborne pathogen. It is spread through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Measles is a highly contagious virus that lives in the nose and throat mucus of an infected person. It can spread to others through coughing and sneezing, and the measles virus can live for up to two hours in an airspace where the infected person coughed or sneezed. Therefore, a patient with measles requires airborne precautions.

Choice D rationale

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. It spreads through close contact with respiratory droplets when an infected person coughs or sneezes. It is typically managed with droplet precautions, not airborne precautions.

A. “Have you experienced any nausea or vomiting with your headache?” B. “Are the lights in this room bothering you?” C. “Have you noticed any confusion or clouded thinking?” D. “Did you feel weak before the headache started or do you feel weak now?”

Correct Answer is A

Explanation

Choice A rationale

Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.

Choice B rationale

Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.

Choice C rationale

While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.

Choice D rationale

Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.

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A nurse is assessing a patient who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

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