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
Dyspnea
Hyperthermia
Urticaria
The Correct Answer is B
A. Headache can be a common side effect of blood transfusion but is not typically considered an urgent or life-threatening complication requiring immediate reporting.
B. Dyspnea (difficulty breathing) can indicate a serious transfusion reaction such as transfusion- related acute lung injury (TRALI) or circulatory overload and should be reported immediately to the provider for further evaluation and intervention.
C. Hyperthermia (elevated body temperature) may indicate a febrile reaction to the transfusion but is not as immediately life-threatening as dyspnea.
D. Urticaria (hives) is a common allergic reaction to blood transfusion but is not typically considered as urgent or life-threatening as dyspnea.
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Related Questions
Correct Answer is C
Explanation
A. This technique is used for children, not adults. To straighten the ear canal for adults, the pinna should be pulled upwards and back.
B. Cleansing the outer ear with isopropyl alcohol is not typically necessary before administering otic medication and may cause irritation to the delicate skin of the ear canal.
C. Holding the dropper 1 cm away allows for better control and accuracy when directing the medication droplets into the ear canal. This helps ensure the medication reaches the intended area within the middle ear. Holding the dropper too close could accidentally touch the ear canal or eardrum, causing discomfort or even injury. Maintaining a slight distance helps prevent the dropper tip from contaminating the ear canal with skin flora from the client or the nurse's hand.
D. While some otic medications might recommend staying still for a short time after administration, 10 minutes is an excessive timeframe for most medications.
Correct Answer is D
Explanation
A. Providing teaching without expecting the client to respond does not facilitate communication or ensure the client understands the information. The goal is to enhance communication, not to bypass it.
B. Speaking with a loud voice is unnecessary and can be counterproductive. Expressive aphasia affects the client’s ability to express themselves, not their hearing. Speaking loudly will not improve the client's ability to understand or communicate.
C. Avoiding facial gestures is not recommended. Non-verbal communication, such as facial expressions and gestures, can be valuable in helping the client understand the information being conveyed.
D. Determining the client’s ability to use a communication board is the most appropriate action. A communication board can help the client express their needs and understand instructions more effectively, making it a valuable tool for reinforcing teaching in clients with expressive aphasia.
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