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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Non-pharmacological options, like acupressure or aromatherapy, address nausea without medication risks. These interventions stimulate the parasympathetic nervous system or reduce gastric irritation, providing relief. Acting first with these methods is safe, effective, and aligns with holistic care, especially when the next antiemetic dose is not yet due.
Choice B reason: Notifying the provider after rounds delays intervention, as nausea requires prompt relief to prevent distress or vomiting. This approach does not address the client’s immediate need and may prolong discomfort. Non-pharmacological methods should be tried first, as they are within the nurse’s scope and can provide quicker relief.
Choice C reason: Discussing anesthesia’s role in nausea provides education but does not alleviate the client’s current symptoms. This cognitive approach addresses understanding, not immediate comfort. While education is valuable, the priority is relieving nausea, making non-pharmacological interventions a more appropriate first step in this scenario.
Choice D reason: Explaining that no other medications are ordered dismisses the client’s discomfort and does not provide relief. This approach fails to utilize the nurse’s scope to implement non-pharmacological interventions, which can effectively manage nausea. It may also reduce trust, as it does not address the client’s immediate needs.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.