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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Keeping the environment warm can help prevent the vasoconstriction that can exacerbate PAD symptoms.
Choice B reason: Resting with the legs above heart level is not typically recommended for PAD as it can reduce arterial blood flow to the legs.
Choice C reason: Applying a heating pad is not recommended for clients with PAD because they may have decreased sensation and could suffer burns.
Choice D reason: Wearing antiembolic stockings during the day can help improve circulation, which is beneficial for clients with PAD.
Correct Answer is C
Explanation
Choice A reason: While limit-setting is important, it should not be overly strict as it can increase anxiety in patients who are already highly anxious.
Choice B reason: Increasing environmental stimuli may overwhelm a highly anxious patient rather than help them.
Choice C reason: Providing support and a therapeutic milieu offers a safe and structured environment, which can help reduce anxiety and promote healing.
Choice D reason: More freedom can be beneficial, but it must be balanced with the need for a supportive and structured environment for a highly anxious patient.
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