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. Conducting staff communications away from the client's room reduces noise levels near the client, promoting a quieter environment conducive to sleep.
B. Minimizing unnecessary entries into the client's room during the night helps prevent disruptions to sleep.
C. Turning on the client's TV introduces additional noise and stimulation, which may further disrupt sleep.

D. Alarms on bedside monitoring equipment should not be turned off unless clinically appropriate to ensure the client's safety.

A. Removing the client's dentures from their mouth B. Washing the client's face C. Closing the client's eyes D. Gathering the client's personal belongings

Correct Answer is A

Explanation

A. Removing the client's dentures should be performed by a licensed nurse rather than an assistive personnel to ensure proper handling and documentation.
B. Washing the client's face is appropriate postmortem care.
C. Closing the client's eyes is appropriate postmortem care.
D. Gathering the client's personal belongings is appropriate postmortem care.

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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 on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

Correct Answer is A

Explanation

A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

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