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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Room number: Room number is not a reliable client identifier because clients can be moved or rooms reassigned, which increases the risk of medication errors or misidentification.
B. Photo identification: Using photo identification is a reliable way to confirm the client’s identity, ensuring that medications are given to the correct person by visually matching the client’s face.
C. Diagnosis: Diagnosis alone is not a unique identifier since multiple clients can share the same diagnosis, and it does not confirm identity for medication administration purposes.
D. Facility-assigned identification number: This number is a unique identifier assigned to each client and is commonly used in healthcare settings to verify identity accurately before medication administration.
E. Date of birth: Date of birth is a reliable identifier to cross-check client identity, especially when used with other identifiers, reducing the risk of errors during medication administration.
Correct Answer is B
Explanation
A. "I should stop receiving Papanicolaou tests once I reach menopause”: Discontinuing Pap tests solely based on menopause is not recommended. Screening continues until at least age 65, depending on the individual's health history and prior screening results. Regular cervical cancer screening is important for early detection, even after menstruation stops.
B. "I might have headaches due to a decline in my estrogen levels”: Fluctuating and declining estrogen levels during perimenopause can trigger headaches or worsen existing ones. Hormonal changes affect blood vessels and neurotransmitters, contributing to the development of migraines or tension headaches in many women during this stage.
C. "The best time to perform a breast self-examination is on the first day of my period”: The ideal time is 7 to 10 days after the start of the menstrual period, when hormonal influence on breast tissue is minimal. Performing it on the first day of menstruation may result in increased tenderness and swelling, making it harder to detect abnormalities.
D. "I can expect to have regular periods until I am in menopause.": Perimenopause is typically marked by irregular menstrual cycles due to hormonal shifts. Periods may become lighter, heavier, more or less frequent before stopping altogether.
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