A nurse is caring for a male client on a medical-surgical unit.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The nurse suspects that the client has developed
The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Rationale for correct choices:
• Transfusion-associated circulatory overload: Characterized by dyspnea, cough, crackles in the lungs, jugular vein distention, and hypertension due to fluid overload during transfusion. The client’s findings of shortness of breath, cough, crackles, and distended neck veins directly align with this condition.
• Lung sounds: The presence of new crackles bilaterally along with dyspnea indicates fluid overload affecting pulmonary circulation, consistent with TACO.
Rationale for incorrect choices:
• Acute intravascular hemolytic reaction: This reaction presents with flank pain, fever, chills, and hemoglobinuria due to incompatible blood. The client shows no evidence of hematuria, fever spike, or severe back pain.
• Anaphylactic reaction: Anaphylaxis occurs rapidly, with symptoms such as bronchospasm, hypotension, urticaria, and possible shock. The client does not have a rash, hives, or hypotension, which rules this out.
• Febrile nonhemolytic reaction: Typically presents with fever, chills, and headache caused by donor WBCs. The client’s temperature is stable and no chills are reported, so this does not match.
• Sepsis transfusion reaction: This occurs when contaminated blood is transfused, leading to fever, hypotension, and rigors. The client is not hypotensive or febrile, making this less likely.
• Temperature: A temperature rise would point to a febrile or septic transfusion reaction, but the client’s temperature remained stable.
• Urticaria: Urticaria would suggest an allergic or anaphylactic reaction, which was not observed.
• Hypotension: Hypotension is seen with hemolytic or septic reactions, but this client’s blood pressure is elevated, not decreased.
• Chills: Chills are typical of febrile or hemolytic reactions, but the client did not report them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in): Palpation assesses tenderness, masses, or organ enlargement but does not evaluate peristalsis. Palpating too soon postoperatively can also cause discomfort or disrupt healing.
B. Auscultate each of the four quadrants for 5 min before determining sounds are absent: Bowel sounds indicate peristalsis, and a full 5 minutes of auscultation is required before concluding they are absent, especially after abdominal surgery where bowel activity may be reduced.
C. Percuss each of the four quadrants of the abdomen: Percussion evaluates the presence of fluid, gas, or organ borders but does not provide information about bowel motility. It is useful for assessing distention but not peristalsis.
D. Inspect each of the four quadrants for abdominal distention: Inspection identifies visible abnormalities such as distention, scars, or pulsations. While distention may suggest reduced peristalsis, visual inspection alone does not confirm bowel activity.
Correct Answer is A
Explanation
A. Determine the source of the client's stress: The first step in managing insomnia related to stress is assessing and identifying the underlying cause. Understanding the source allows the nurse to tailor interventions effectively and ensures that care addresses the root of the problem rather than just the symptoms.
B. Instruct the client to turn off their TV just before they go to bed: Reducing screen time before sleep is helpful in promoting rest, but this is a specific behavioral strategy. It should follow an assessment of the client’s stressors and sleep patterns to be applied appropriately.
C. Encourage the client to listen to soft music at the onset of stress: Relaxation techniques such as music therapy can aid stress reduction, but they are supportive measures. Without assessing the client’s unique stressors first, these interventions may not fully address the insomnia.
D. Advise the client to exercise daily in the morning: Morning exercise can improve sleep quality and reduce stress, but it is a long-term strategy. The nurse must first explore the client’s stress triggers to ensure that interventions are individualized and effective.
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