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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.
B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.
C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.
D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.
Correct Answer is B
Explanation
Rationale:
A. A BMI of 30 or higher is classified as obese.
B. A BMI between 25 and 29.9 is classified as overweight.
C. A BMI below 18.5 is classified as underweight.
D. A BMI between 18.5 and 24.9 is classified as ideal body weight.
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