A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Hemolysis

Urticaria

Fever

Fluid overload

Answer and Explanation

The Correct Answer is B

A. Hemolysis: This is a severe reaction to blood transfusion involving the destruction of red blood cells and requires different management strategies.

B. Urticaria: Diphenhydramine is used to prevent or treat urticaria (hives), which is a mild allergic reaction and can be managed with antihistamines.

C. Fever: This is typically managed with antipyretics or by addressing the underlying cause rather than antihistamines.

D. Fluid overload: This condition requires management with diuretics and careful monitoring of fluid intake rather than antihistamines.

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Correct Answer is A

Explanation

A. Administer the medication using a Z-track technique: This is correct as ceftriaxone should be administered using the Z-track technique to prevent leakage of the medication into the subcutaneous tissue and minimize irritation.

B. Administer the medication using a 5/8-inch needle: A longer needle is typically needed for IM injections to reach the muscle tissue, so a 5/8-inch needle is not appropriate.

C. Administer the medication in the deltoid muscle: Ceftriaxone is usually administered in the larger muscle groups such as the ventrogluteal or vastus lateralis muscles rather than the deltoid.

D. Administer the medication at a 45° angle: IM injections are generally given at a 90° angle to ensure that the medication is properly deposited into the muscle tissue.

A. Provide a schedule of visiting hours to the client's family. B. Develop a plan of care for the client. C. Teach the client about his diagnosis. D. Document the client's allergies in the electronic medical record.

Correct Answer is D

Explanation

A. Provide a schedule of visiting hours to the client's family: While this is important, it is not a priority in the context of initial assessment and history.

B. Develop a plan of care for the client: Developing a plan of care is important but should come after completing the initial assessment and gathering all necessary information.

C. Teach the client about his diagnosis: Teaching about the diagnosis is important but is not a priority over ensuring that crucial health information, such as allergies, is documented.

D. Document the client's allergies in the electronic medical record: Documenting allergies is the priority as it is crucial for preventing potential allergic reactions and ensuring the safety of the client during their care.

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A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Nursing Test Bank

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Correct Answer is D

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