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 C

Explanation

Choice A reason: Increasing sodium intake raises blood pressure by promoting fluid retention, increasing vascular volume, and straining the cardiovascular system. Hypertensive clients need sodium restriction to reduce fluid overload and vascular resistance, making this recommendation harmful, as it exacerbates hypertension rather than controlling it.

Choice B reason: A diet high in saturated fats contributes to atherosclerosis, increasing vascular resistance and blood pressure. It also raises LDL cholesterol, worsening cardiovascular risk. Hypertensive clients require heart-healthy diets low in saturated fats to reduce blood pressure and protect against heart disease, making this inappropriate.

Choice C reason: The DASH (Dietary Approaches to Stop Hypertension) diet, rich in fruits, vegetables, and low-fat dairy, reduces blood pressure by providing potassium, magnesium, and fiber. These nutrients lower vascular resistance and promote vasodilation, improving cardiovascular health. It is evidence-based and recommended for hypertension management, making it the best choice.

Choice D reason: Limiting potassium-rich foods is not recommended for hypertension, as potassium promotes vasodilation and reduces blood pressure by counteracting sodium’s effects. Potassium-rich foods, like fruits, are part of the DASH diet, which helps control hypertension, making this recommendation incorrect for blood pressure management.

A. Have you been having swelling in your legs? B. Have you been experiencing difficulty breathing? C. Have you been experiencing chest pain? D. Have you been experiencing heart palpitations?

Correct Answer is B

Explanation

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.

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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 teaching a client with hypertension about dietary modifications. Which recommendation is most appropriate to reduce blood pressure?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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