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?
Hyperthermia
Urticaria
Dyspnea
Headache
The Correct Answer is C
Rationale:
A. Hyperthermia may indicate a transfusion reaction, but dyspnea is a more immediate concern.
B. Urticaria may indicate a mild allergic reaction, but dyspnea is a more immediate concern.
C. Dyspnea is a sign of a possible transfusion reaction and should be reported immediately to the provider.
D. A headache may indicate a mild reaction to the blood transfusion, but dyspnea is a more immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.
B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.
C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.
D. Explaining why her participation is important may not address the client's concerns or fears.
Correct Answer is C
Explanation
Rationale:
A. Cleansing the client's outer ear with isopropyl alcohol to remove wax is not recommended because it can cause irritation and dryness.
B. Pulling the client's pinna downward and back is an incorrect technique for instilling otic medication in an adult client. An adult ear should be pulled upwards and backwards.
C. Holding the ear dropper 1 cm (0.5 in) from the client's ear is accurate.
D. Requesting the client remain supine for 10 min following administration is not necessary and may not be practical, instead the client should lie on the contralateral side.
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