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 A

Explanation

A. Telling the APs to stop the conversation is correct. Discussing client information in a public area violates HIPAA (Health Insurance Portability and Accountability Act) privacy regulations. The nurse should immediately intervene and remind the APs about maintaining client confidentiality.

B. Documenting the event in the client's progress notes is incorrect. Client progress notes should contain only information relevant to client care. Documenting an overheard conversation about a privacy violation does not belong in the medical record.

C. Informing the client of the APs' actions is incorrect. While privacy is essential, informing the client may cause unnecessary distress. The nurse should focus on correcting the behavior of the APs rather than alarming the client.

D. Submitting an incident report to the risk manager is incorrect. While some breaches of confidentiality require reporting, the first step is to address the issue directly with the APs. If the behavior continues or is severe, reporting to a supervisor may be necessary.

A. Take the medication and then lay down for 30 min. B. Take the medication with an antacid. C. Take the medication with calcium-fortified orange juice. D. Take the medication with crackers.

Correct Answer is D

Explanation

A. "Take the medication and then lay down for 30 min.": This is not recommended. Lying down after taking doxycycline can increase the risk of esophageal irritation and ulceration. It is best to remain upright for at least 30 minutes after taking the medication.

B. "Take the medication with an antacid.": This is incorrect. Antacids can interfere with the absorption of doxycycline and reduce its effectiveness. It is important to avoid antacids, calcium supplements, and iron supplements within 2 hours of taking doxycycline.

C. "Take the medication with calcium-fortified orange juice.": This is incorrect. Calcium can bind with doxycycline, reducing its absorption and effectiveness. It is best to avoid taking doxycycline with calcium-rich products like milk or fortified juices.

D. "Take the medication with crackers.": This is correct. Taking doxycycline with a small amount of food, like crackers, can help reduce gastrointestinal discomfort, such as nausea and vomiting. It is recommended to take doxycycline with food if nausea occurs, though not with dairy or antacids.

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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

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Explanation

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Explanation

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