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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensure that the stool specimen does not contain urine: Fecal occult blood tests are designed to detect blood in the stool, so it's important to ensure that the specimen
collected is not contaminated with urine, which could yield a false-positive result.
B. Wear sterile gloves when handling the stool specimen: Sterile gloves are not typically required for handling stool specimens for fecal occult blood testing. Standard
precautions, including hand hygiene and wearing non-sterile gloves, are sufficient.
C. Repeat the test three times using the same stool specimen: The test is typically
performed once on a fresh stool specimen, and repeating the test with the same specimen is not recommended.
D. Have the client defecate into a bedpan that contains a small amount of water: Fecal occult blood testing requires a small sample of stool collected from a bowel movement. Using a bedpan with water may dilute the stool and affect the accuracy of the test.
Correct Answer is ["B","C","D"]
Explanation
A. A temperature of 37.5° C (99.5° F) is slightly elevated but can be expected postoperatively and does not typically require immediate intervention.
B. The client being difficult to arouse is concerning following opioid administration, as it may indicate over-sedation or the onset of respiratory depression. This requires immediate nursing action.
C. A respiratory rate of 10/min is low and can be a sign of opioid-induced respiratory depression, especially when combined with difficulty arousing the client. This is a critical value that
necessitates prompt nursing assessment and intervention.
D. Pulse oximetry of 88% on room air is below the normal range and indicates hypoxemia. This is a serious finding that requires immediate action to improve the client's oxygenation.
E. Pupils that are 3 mm, equal, and reactive to light, along with a blood pressure of 99/46 mm Hg, while on the lower side, are not as immediately concerning as the respiratory rate and level of consciousness.
F. A heart rate of 61/min is within normal limits and does not typically require intervention unless there are other signs of hemodynamic instability.
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