A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Confusion

Increased urinary output

Increased intracranial pressure

Weakness

Answer and Explanation

The Correct Answer is D

A. Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.

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Correct Answer is A

Explanation

A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.

B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.

C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.

D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.

A. Febrile B. Acute pain C. Allergic D. Hemolytic

Correct Answer is D

Explanation

A. A febrile reaction is typically characterized by fever and chills but does not usually cause red-tinged urine.
B. Acute pain is not a specific reaction associated with blood transfusions and does not match the described symptoms.
C. An allergic reaction is more likely to cause hives or itching rather than fever and red-tinged urine.
D. Hemolytic transfusion reactions are associated with fever, chills, and red-tinged urine due to the breakdown of red blood cells and are a serious complication that requires immediate attention.

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A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Correct Answer is D

Explanation

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