The client, admitted with an acute gastrointestinal bleed, is being treated with a transfusion of 2 units of packed red blood cells. The client is demonstrating shortness of breath, new cough, increased blood pressure, jugular venous distention, and tachycardia. How should the nurse interpret these findings? The client is experiencing this type of transfusion reaction:

circulatory overload

febrile

bacteria

transfusion related acute lung injury

Answer and Explanation

The Correct Answer is A

A. Circulatory overload: Shortness of breath, cough, increased blood pressure, jugular venous distention, and tachycardia indicate circulatory overload. This occurs when the blood volume from transfusions exceeds the heart’s ability to handle it, causing fluid accumulation in the lungs.

B. Febrile: Febrile reactions are characterized by fever and chills, often due to cytokine release or an immune response. The symptoms here, especially cardiovascular changes, point to circulatory overload rather than a febrile response.

C. Bacteria: Bacterial contamination of blood products causes sepsis, usually with fever, chills, and signs of infection. The symptoms described are more indicative of circulatory overload than an infection.

D. Transfusion-related acute lung injury (TRALI): TRALI causes acute respiratory distress and hypoxia, without significant blood pressure changes. The signs of circulatory overload, including elevated blood pressure, suggest this is not TRALI.

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Correct Answer is A

Explanation

A. Ensure the patient understands the risks and benefits involved with this treatment: Clear information about the risks and benefits of a bone marrow transplant helps the patient make an informed decision based on their health, personal preferences, and understanding of the procedure.

B. Explain that a cure is not possible with any other type of treatment: While bone marrow transplant can be a potential cure, this is not the case for all patients. Other treatments, such as targeted therapy, may be effective, so stating that no other treatments work is not accurate.

C. Encourage the patient to ask what new and experimental treatments are available: The nurse's primary role is to ensure the patient fully understands the established treatment options and their potential outcomes. Experimental treatments may not be suitable for all patients.

D. Emphasize the positive aspects of the procedure for both donor and recipient: Focusing only on the positive aspects without acknowledging the risks could lead to an unrealistic view of the transplant. A balanced approach is needed to ensure informed decision-making.

A. Periodontal disease and gum surgery three months ago B. Breast cancer treated with chemotherapy and radiation C. Type I diabetic for ten years D. Myocardial infarction one year ago

Correct Answer is ["A","C","E","G"]

Explanation

A. Smoking: Smoking is a well-established risk factor for many cancers, including penile cancer. It weakens the immune system and damages DNA, increasing the risk of cancer development.

B. High dietary fiber intake: High dietary fiber intake is not a risk factor for penile cancer. In fact, a healthy diet rich in fiber can help lower the risk of various cancers, including colorectal cancer, but it is not linked to penile cancer.

C. History of genital warts: A history of genital warts, caused by certain strains of the human papillomavirus (HPV), is a significant risk factor for penile cancer. HPV infection can cause changes in penile cells that may lead to cancer.

D. Alcohol consumption: While excessive alcohol consumption is a risk factor for several cancers (e.g., head and neck, liver, esophageal), it is not consistently identified as a direct or strong independent risk factor for penile cancer
E. Age over 70 years: Older age is a significant risk factor for most cancers, including penile cancer. The incidence of penile cancer generally increases with advancing age, with the majority of cases

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Naxlex Comprehensive Predictor Exams

A 45-year-old client with chronic myelocytic leukemia (CML) is considering a bone marrow transplant from a sibling. How should the nurse assist this client with treatment decisions?

Correct Answer is A

Explanation

The nurse is caring for a client with suspected infectious endocarditis. Which information obtained in the health history could contribute to the development of this problem?

Correct Answer is ["A","C","E","G"]

Explanation

Malignant plasma cells secrete substances to stimulate the creation of new blood vessels to enhance the growth of the clusters of plasma cells. This is the process of

When teaching a patient about multiple myeloma, which intervention should the nurse stress to the client?

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