A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

Temperature 38.8° C (101.8° F)

Straw-colored urine

Apical pulse rate 58/min

Blood pressure 158/92 mm Hg

Answer and Explanation

The Correct Answer is A

The correct answer is: a. Temperature 38.8° C (101.8° F)

Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.

Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.

Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.

Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.

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Correct Answer is D

Explanation

a.Frequent bathing can actually worsen dry, itchy skin as it can strip away the natural oils that help moisturize the skin. Instead, the nurse should encourage the client to limit bathing to shorter durations using lukewarm water and gentle, fragrance-free cleansers.

b.Powder may not provide significant relief for dry, itchy skin and can potentially irritate the skin further. It is best to focus on moisturizing and hydrating the skin to alleviate the symptoms.

c.While this might seem helpful, oils in the bath can create a slippery surface, posing a fall risk, especially for older adults. Additionally, oils might not provide sufficient hydration to the skin and could leave a residue that is not always beneficial.

d.Dry, itchy skin is a common concern among older adults, and it can be exacerbated by low humidity levels. Placing a humidifier in the client's room helps to increase the moisture content in the air, which can alleviate dryness and itchiness. The increased humidity can help prevent the skin from becoming overly dry and can provide relief from the symptoms.

A. Assist the client to the orthopneic position. B. Instruct the client to remain as still as possible during the recording. C. Attach a blood pressure cuff to the client's upper arm. D. Tell the client to expect a mild stinging sensation during the test.

Correct Answer is B

Explanation

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

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A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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