A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Vital Signs
0800:
Blood pressure 112/64 mm Hg
Heart rate 80/min
Respiratory rate 18/min
Temperature 37.1° C (98.8" F
Oxygen saturation 97% on room air
08151
Blood pressure 106/54 mm Hg Heart rate 100/min
Respiratory rate 22/min Temperature 37° C (98,6°F)
Oxygen saturation 95% on room air
Complete the following sentence by using the lists of options.
The client has manifestations of an , as evidenced by the
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Cantaloupe is relatively high in potassium and is not a suitable choice for a low-potassium diet.
B: Baked potatoes are high in potassium and should be avoided in a low-potassium diet.
C: Banana chips are also high in potassium and should not be included in a low-potassium diet.
D: Correct. Applesauce is a low-potassium food and is an appropriate choice for a client with chronic kidney disease following a low-potassium diet.
Correct Answer is C
Explanation
A. Place the client's medication record on the bedside table while ambulating the client: This action does not relate to protecting the client's privacy. It might actually compromise confidentiality by leaving sensitive information exposed.
B. Give a report about the client's status while standing at the nurses' station: This action does not protect the client's privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality.
C. Speak with the client about their condition after visitors have left: Correct. Protecting the client's privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality.
D. Place a message board in the client's room to post dietary information: This action does not relate to protecting the client's privacy. Posting dietary information may be helpful for staff, but it doesn't address the client's privacy concerns.
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