A nurse is monitoring a client receiving a blood transfusion. Which symptom indicates a potential transfusion reaction that requires immediate action?

Mild itching at the infusion site

Slight increase in heart rate

Sudden chills and fever

Minor redness around the IV site

Answer and Explanation

The Correct Answer is C

Choice A reason: Mild itching may indicate a minor allergic reaction to a transfusion, caused by sensitivity to donor plasma proteins. While concerning, it is not immediately life-threatening and can often be managed with antihistamines. Severe symptoms like fever and chills take priority, as they suggest more dangerous reactions like hemolytic or febrile responses.

Choice B reason: A slight increase in heart rate can occur due to anxiety or fluid volume changes during transfusion but is not specific to a transfusion reaction. It is less urgent than fever and chills, which indicate a potentially severe reaction like hemolysis or infection, requiring immediate cessation of the transfusion.

Choice C reason: Sudden chills and fever during a transfusion suggest a febrile non-hemolytic reaction or, more critically, a hemolytic reaction or sepsis. These can cause systemic inflammation, hemolysis, or shock, requiring immediate stopping of the transfusion, assessment, and intervention to prevent life-threatening complications like renal failure or disseminated intravascular coagulation.

Choice D reason: Minor redness at the IV site may indicate local irritation or phlebitis, not a systemic transfusion reaction. It is less urgent than systemic symptoms like fever and chills, which signal severe reactions requiring immediate action. Local symptoms can be monitored and managed without stopping the transfusion.

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Correct Answer is B

Explanation

Choice A reason: pH 7.48, PaCO2 40 mmHg, HCO3- 24 mEq/L indicates alkalosis, not acidosis. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to ketone accumulation, lowering pH and bicarbonate. Normal PaCO2 and HCO3- rule out DKA, as compensatory hyperventilation would lower PaCO2 in response to acidosis.

Choice B reason: pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L indicates metabolic acidosis with respiratory compensation. In DKA, ketone production lowers pH and bicarbonate, while hyperventilation reduces PaCO2 to compensate. These values align with DKA’s acid-base imbalance, reflecting the body’s attempt to correct acidosis through increased respiration.

Choice C reason: pH 7.50, PaCO2 45 mmHg, HCO3- 30 mEq/L indicates metabolic alkalosis, not acidosis. DKA causes acidosis from ketone accumulation, not alkalosis. Elevated bicarbonate and normal PaCO2 suggest a different condition, like vomiting-induced alkalosis, making this inconsistent with the metabolic acidosis seen in DKA.

Choice D reason: pH 7.35, PaCO2 38 mmHg, HCO3- 22 mEq/L indicates normal acid-base balance. DKA results in metabolic acidosis with low pH and bicarbonate due to ketone production. Normal values do not reflect the acidotic state of DKA, where compensatory mechanisms would alter PaCO2 and HCO3- significantly.

A. Weight gain B. Bradycardia C. Heat intolerance D. Constipation

Correct Answer is C

Explanation

Choice A reason: Weight gain is associated with hypothyroidism, not hyperthyroidism. Hyperthyroidism increases metabolic rate, leading to weight loss due to increased calorie expenditure. The thyroid hormones accelerate metabolism, causing catabolism, which contrasts with the client’s likely symptom of weight loss, not gain, in hyperthyroidism.

Choice B reason: Bradycardia, or slow heart rate, occurs in hypothyroidism due to decreased metabolic rate. Hyperthyroidism causes tachycardia, as elevated thyroid hormones increase sympathetic activity, raising heart rate and cardiac output. The client’s symptoms would likely include a rapid heart rate, not bradycardia, in this condition.

Choice C reason: Heat intolerance is a classic symptom of hyperthyroidism due to increased metabolic rate from elevated thyroid hormones. This causes excessive heat production, leading to sweating and discomfort in warm environments. The symptom aligns with the hypermetabolic state, making it the most likely to be reported.

Choice D reason: Constipation is associated with hypothyroidism, where decreased metabolism slows gastrointestinal motility. Hyperthyroidism increases motility, often causing diarrhea. The client with hyperthyroidism is unlikely to report constipation, as their condition accelerates digestive processes, contrasting with the slowed motility seen in hypothyroidism.

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A nurse is monitoring a client receiving a blood transfusion. Which symptom indicates a potential transfusion reaction that requires immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas result is most consistent with this condition?

Correct Answer is B

Explanation

A nurse is caring for a client with a new diagnosis of hyperthyroidism. Which symptom is most likely to be reported by this client?

Correct Answer is C

Explanation

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