A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?

Headache

Urticaria

Dyspnea

Hyperthermia

Answer and Explanation

The Correct Answer is C

A. Headache: Headache can occur during a transfusion reaction but is usually a less urgent symptom. It should be monitored but is not the highest priority.

B. Urticaria: Urticaria (hives) often indicates a mild allergic reaction to the transfusion. It requires intervention but is generally not immediately life-threatening.

C. Dyspnea: Dyspnea signals possible respiratory distress, which may indicate a severe transfusion reaction such as anaphylaxis or transfusion-related acute lung injury (TRALI). This requires immediate attention and reporting to prevent respiratory failure.

D. Hyperthermia: A fever during transfusion suggests a febrile non-hemolytic reaction or infection risk, which is important but typically not as urgent as respiratory distress.

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Correct Answer is D

Explanation

A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.

B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.

C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.

D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.

A. Repeat each exercise 10 times. B. Increase flexion during a muscle spasm. C. Support each extremity above and below the joint. D. Move the joint just past the point of resistance.

Correct Answer is C

Explanation

A. Repeat each exercise 10 times: Performing passive range of motion exercises 3 to 5 times per joint is usually enough to maintain joint flexibility and prevent stiffness. Repeating the exercises excessively may cause muscle fatigue or irritation, especially in immobile clients. The goal is to promote mobility without causing discomfort or harm.

B. Increase flexion during a muscle spasm: Forcing movement during a muscle spasm can increase pain and potentially cause injury to muscles or joints. The nurse should gently stop the exercise when a spasm occurs and allow the muscle to relax before continuing. Careful, slow movements help prevent exacerbation of muscle spasms.

C. Support each extremity above and below the joint: Supporting the extremity above and below the joint stabilizes the joint and surrounding tissues, reducing the risk of injury during passive movement. This technique also helps control the movement and minimizes discomfort for the client. Proper support is essential for safe and effective passive range of motion exercises.

D. Move the joint just past the point of resistance: Moving a joint beyond the point of resistance can cause tissue damage, pain, and joint injury. The nurse should stop movement at the point of resistance or the onset of discomfort, never forcing further motion. Respecting this limit preserves joint integrity and client safety.

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A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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