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 D

Explanation

A. Stating that palliative care is only for clients with a terminal illness is incorrect. Palliative care is designed for clients with serious, chronic, or life-threatening illnesses and focuses on symptom management and quality of life, regardless of prognosis.

B. Limiting palliative care to those with 6 months or less to live is incorrect. This definition applies to hospice care, not palliative care. Palliative care can be provided alongside curative treatments at any stage of illness.

C. Including restriction of nutritional support is incorrect. Palliative care emphasizes comfort and symptom relief, including providing adequate nutrition and hydration as appropriate for the client’s needs and wishes.

D. Enhancing quality of life by promoting comfort is correct. Palliative care aims to relieve symptoms such as pain, nausea, and fatigue while supporting the client’s emotional, psychological, and spiritual well-being.

A. Contact the client's caregiver to discuss the client's comment. B. Review the medical record to see if the client has reported abuse in the past. C. Report the suspected abuse to the nurse manager. D. Restrict family members from visiting with the client.

Correct Answer is B

Explanation

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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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 reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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