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. 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.
Correct Answer is B
Explanation
A. The client waits 10 min between inhalations: Waiting 10 minutes between inhalations is unnecessary for a rescue inhaler like albuterol. Typically, it is sufficient to wait for 1 to 2 minutes if more doses are required.
B. The client holds his breath for 10 seconds after inhaling the medication: This is correct. Holding the breath for about 10 seconds after inhalation allows the medication to settle in the airways and enhances its effectiveness.
C. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. A slow, deep inhalation is recommended to ensure that the medication reaches the lower airways.
D. The client exhales as the medication is released from the inhaler: This is incorrect. The client should exhale fully before inhaling the medication to ensure that the medication can be inhaled deeply into the lungs.
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