A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Anaphylactic

Acute hemolytic

Febrile

Circulatory overload

Answer and Explanation

The Correct Answer is A

A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.

B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.

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Correct Answer is B

Explanation

A. Alternate daily caregivers is incorrect. Consistent caregiving is important for clients experiencing delirium to provide stability and reduce confusion. Frequent changes in caregivers can increase anxiety and disorientation.

B. Remind the client of the day and time often is correct. Frequent reminders of the day, time, and orientation help ground the client in reality and reduce confusion. This is an essential part of managing delirium by addressing disorientation and improving cognitive clarity.

C. Offer the client several choices at mealtimes is incorrect. Giving too many choices can lead to overwhelm and confusion in clients with delirium. It is better to offer simple, limited options to avoid stress or difficulty in decision-making.

D. Avoid discussing the client's fears is incorrect. Addressing a client's fears is important in the management of delirium. It is more beneficial to acknowledge and provide reassurance, which can help reduce anxiety and the psychological stress that might exacerbate delirium.

A. The AP points the probe posteriorly. B. The AP pulls the pinna up and back. C. The AP positions the client facing her. D. The AP inserts the probe with a straight, forward motion.

Correct Answer is B

Explanation

A. The AP points the probe posteriorly is incorrect. When using a tympanic thermometer for adults or children older than 3 years, the probe should be directed posteriorly and slightly upwards to align with the ear canal. The posterior direction is correct for adults, but this phrasing is not precise enough for the intended technique.

B. The AP pulls the pinna up and back is correct. When taking the temperature of a client older than 3 years using a tympanic thermometer, the pinna (ear) should be pulled up and back to straighten the ear canal and ensure accurate measurement. This action indicates the AP understands proper technique.

C. The AP positions the client facing her is incorrect. The client’s position does not directly affect the ability to take a tympanic temperature. The focus should be on positioning the ear and probe, not on facing the nurse.

D. The AP inserts the probe with a straight, forward motion is incorrect. The correct motion is straight into the ear canal, not forward, and it is more precise when the probe is inserted gently without forcing it.

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A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is B

Explanation

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