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
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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Related Questions
Correct Answer is D
Explanation
A. A client who is being discharged to a long-term care facility: This may involve extensive discharge teaching and planning, which may not align with the float nurse’s PACU experience.
B. A client who needs teaching prior to initiating cardiac rehabilitation activities: This requires specialized knowledge in cardiac rehabilitation and patient education.
C. A client who needs teaching about insulin self-administration: This requires specific knowledge about diabetes management and patient education.
D. A client who is postoperative following a lobectomy and has a chest tube: The float nurse from the PACU is likely familiar with postoperative care and management of chest tubes, making this client the most suitable for their expertise.
Correct Answer is C
Explanation
A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side: The direction of the snap is not as critical as ensuring the use of proper technique to avoid injury and contamination.
B. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion: Breaking the ampule downward could risk contamination and injury if not done properly.
C. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body: This method minimizes the risk of glass shards and helps to prevent injury and contamination, ensuring safe handling of the medication.
D. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body: Breaking the ampule toward the body is unsafe and increases the risk of injury from glass shards.
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