A nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin.
Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Choice A rationale

Stopping the blood transfusion is critical to prevent the progression of a transfusion reaction, which can be life-threatening. Immediate cessation of the transfusion minimizes the amount of incompatible blood entering the patient’s system, reducing the risk of serious complications such as hemolysis or anaphylaxis. Rapid intervention is necessary to ensure the patient’s safety and to provide time for assessment and implementation of appropriate treatments. Recognizing the signs of a transfusion reaction and acting swiftly is essential in managing the patient’s condition effectively.

Choice B rationale

Administering an antipyretic is not the priority action when a transfusion reaction is suspected. Fever can be a symptom of a transfusion reaction, but stopping the transfusion and assessing the patient are more urgent. Antipyretics like acetaminophen can be given to manage fever, but only after the transfusion is halted and the patient’s overall condition has been evaluated. Addressing the root cause of the reaction takes precedence to prevent further complications.

Choice C rationale

Encouraging oral fluids is not an immediate priority during a transfusion reaction. While maintaining hydration is important, the initial step must be to stop the transfusion and assess the patient’s condition. Oral fluids do not address the underlying issue of the transfusion reaction and are not effective in managing acute symptoms. Prioritizing actions that directly mitigate the reaction is essential for patient safety.

Choice D rationale

Applying supplemental oxygen may be necessary if the patient exhibits signs of respiratory distress during a transfusion reaction. However, the first action should be to stop the transfusion to prevent further exposure to the incompatible blood product. Oxygen can be administered as a supportive measure after the transfusion is halted and the patient’s respiratory status is assessed. Addressing the immediate cause of the reaction is paramount.

Choice E rationale

Sending blood for type and crossmatch is important for identifying the cause of the transfusion reaction and ensuring safe future transfusions. However, this action is not the priority during the acute phase of a reaction. Stopping the transfusion and assessing the patient’s condition must come first to stabilize the patient and prevent further complications. Laboratory testing can be performed once the patient’s immediate needs are addressed.

Choice A rationale

Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom of multiple sclerosis (MS) due to the demyelination of nerve fibers in the central nervous system. While it can be bothersome for the client, it is not typically an immediate life-threatening condition that requires urgent reporting to the healthcare provider. Ongoing management and monitoring of symptoms are important, but paresthesia alone does not necessitate immediate medical intervention.

Choice B rationale

Tremors are another common manifestation of MS, resulting from nerve damage that affects motor pathways. Tremors can significantly impact the client's quality of life, making daily activities challenging. However, like paresthesia, tremors are not usually considered an urgent condition that needs immediate reporting. They should be managed through a comprehensive care plan involving medications and physical therapy.

Choice C rationale

Tinnitus, or ringing in the ears, can occur in individuals with MS due to demyelination affecting the auditory pathways. While tinnitus can be distressing and affect the client's hearing, it is not typically an immediate life-threatening condition. It may require evaluation and symptomatic management, but it does not require urgent reporting unless it is associated with other severe symptoms.

Choice D rationale

Fever in a client with MS could indicate an infection or other inflammatory process, which can exacerbate MS symptoms and lead to a relapse. Fever may also signal a secondary complication such as a urinary tract infection or respiratory infection, which requires prompt medical attention. The healthcare provider should be notified immediately to evaluate and manage the underlying cause of the fever.

Choice E rationale

Tachycardia, or an abnormally rapid heart rate, can be a sign of several serious conditions, including infection, dehydration, or cardiovascular problems. In clients with MS, tachycardia may also indicate an autonomic dysfunction or be a response to fever or other stressors. Immediate reporting to the healthcare provider is necessary to determine the underlying cause and initiate appropriate treatment to prevent complications.