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 D

Explanation

A. Tell the client the physician wants him to take the medications: This does not address the client’s concerns and may not resolve the issue.

B. Document that the client refuses the medications: While documentation is important, the nurse should first address the client’s concerns before documenting.

C. Ask the client why he is refusing to take the medications: Understanding the client’s reasons for refusal is important, but the initial step should be to explain the purpose of the medications.

D. Explain the purpose for the medications: Providing information about the purpose and benefits of the medications helps the client make an informed decision and may address concerns leading to refusal.

A. Administer the medication using a Z-track technique. B. Administer the medication using a 5/8-inch needle. C. Administer the medication in the deltoid muscle. D. Administer the medication at a 45° angle.

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.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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