A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic. reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic

Allergic

Febrile

Bacterial

Answer and Explanation

The Correct Answer is A

A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.

B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.

C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.

D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.

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Correct Answer is A

Explanation

A. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.

B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.

C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.

D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.

A. Cashews B. Oranges C. Red meat D. Yogurt

Correct Answer is C

Explanation

A. Cashews: Cashews contain iron, but the amount is relatively low compared to other sources like red meat.

B. Oranges: Oranges are high in vitamin C, which aids iron absorption, but they are not a significant source of iron.

C. Red meat: Red meat is an excellent source of heme iron, which is highly bioavailable and effectively addresses iron deficiency.

D. Yogurt: Yogurt is not a significant source of iron. It contains other nutrients, but it is not relevant for increasing iron intake.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

Explanation

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?

Correct Answer is C

Explanation

A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?