A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?
Vomiting
Urticaria
Low back pain
Pulmonary congestion
The Correct Answer is C
Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.
Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.
Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.
Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Calling the surgeon to talk to the patient may be helpful in some cases, but it does not directly address the patient's immediate emotional needs. The surgeon can provide detailed information about the procedure, which might alleviate some fears, but this is not always the immediate solution.
Choice B reason:
Offering to call the chaplain for the patient could provide emotional and spiritual support, which is important in holistic care. However, this should be done in addition to addressing the patient's concerns about the surgery itself.
Choice C reason:
Informing the patient that the survival rate for this surgery is very high directly addresses the patient's fear about not surviving the surgery. Providing factual reassurance about the success rate can help to alleviate anxiety and is an appropriate immediate response.
Choice D reason:
Recommending analgesics only during surgery does not address the patient's expressed fear and is not an appropriate response to the emotional concern. Analgesics are for pain management and do not provide reassurance about the outcome of the surgery.
Correct Answer is C
Explanation
Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.
Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.
Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.
Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.
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