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

Answer and Explanation

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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Correct Answer is C

Explanation

A. While poorly fitting dentures can affect nutrition and overall health, they are not immediately life-threatening and do not represent the most urgent concern.

B. This could be a sign of emotional distress or loneliness, but it is not necessarily an urgent issue requiring immediate intervention.

C. Sedentary behavior in older adults is a priority concern because it increases the risk of various health problems, including cardiovascular disease, muscle atrophy, and decreased mobility. Prolonged inactivity can also contribute to the development of conditions like deep vein thrombosis (DVT) and pressure ulcers.

D. Although having no living family may contribute to social isolation and potential support needs, it is not as immediately critical as the potential physical health risks associated with a sedentary lifestyle.

A. Pull the client's pinna downward and back. B. Cleanse the client's outer ear with isopropyl alcohol to remove wax. C. Hold the ear dropper 1 cm (0.5 in) from the client's ear. D. Request the client remain supine for 10 min following administration.

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.

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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

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Explanation

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