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. Administering diuretics in the evening may increase the client's need to urinate and disrupt sleep.
B. Using overhead lighting when checking equipment may disrupt the client's sleep and should be avoided.
C. Keeping the door to the client's room closed can reduce noise and disturbances from the hallway, promoting a more restful sleep environment.
D. Providing snug-fitting nightwear may be uncomfortable and restrict movement during sleep.
Correct Answer is D
Explanation
Rationale:
A. Washing the client's face is part of postmortem care and is appropriate.
B. Gathering the client's personal belongings is part of postmortem care and is appropriate.
C. Closing the client's eyes is part of postmortem care and is appropriate.
D. Removing the client's dentures from their mouth is not part of postmortem care and may be distressing for the family. The nurse should intervene and ensure the dentures are left in place.
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