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 A

Explanation

A. Chvostek's sign is a clinical sign observed during physical examination that may indicate hypocalcemia. It is elicited by tapping or lightly striking the facial nerve just anterior to
the earlobe, which can cause twitching of the facial muscles, particularly the muscles around the mouth and nose.
B. This image shows winging of the scapula. Winging of the scapula, also known as
scapular winging, is a condition characterized by the abnormal protrusion or prominence of the scapula away from the back wall of the thorax. Normally, the scapula lies flat
against the rib cage, providing stability and support for arm movements.

A. "Increase your intake of protein." B. "Use your incentive spirometer." C. "Perform regular isometric exercises." D. "Dangle your legs over the side of the bed."

Correct Answer is D

Explanation

A. Increasing protein intake is not directly related to preventing orthostatic hypotension. While adequate nutrition is essential for overall health and healing postoperatively, it does not
specifically address the risk of orthostatic hypotension.

B. Using an incentive spirometer is beneficial for promoting lung expansion and preventing respiratory complications after surgery but does not directly address orthostatic hypotension.
C. Performing regular isometric exercises may help prevent muscle atrophy and maintain

strength during periods of immobility but does not specifically address orthostatic hypotension.

D. Dangling the legs over the side of the bed before standing helps the body gradually adjust to an upright position, reducing the risk of orthostatic hypotension by allowing the cardiovascular system to acclimate to changes in posture.

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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 collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign? Image A Image B

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

Correct Answer is D

Explanation

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