The nurse is assisting with the care of a client who is receiving a unit of packed RBCs.
Complete the following sentence by using the lists of options. Exhibit 1
The client has manifestations of an
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place the client's medication record on the bedside table while ambulating the client: This action does not relate to protecting the client's privacy. It might actually compromise confidentiality by leaving sensitive information exposed.
B. Give a report about the client's status while standing at the nurses' station: This action does not protect the client's privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality.
C. Speak with the client about their condition after visitors have left: Correct. Protecting the client's privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality.
D. Place a message board in the client's room to post dietary information: This action does not relate to protecting the client's privacy. Posting dietary information may be helpful for staff, but it doesn't address the client's privacy concerns.
Correct Answer is D
Explanation
A. Ask a family member who speaks the client's primary language to interpret: While involving family members may seem helpful, it is not the most effective way to ensure accurate and complete communication. There may be language barriers or misunderstandings.
B. Plan a long teaching session initially to introduce the necessary material: Lengthy teaching sessions may overwhelm the client and reduce their ability to absorb and retain information, especially when there is a language barrier.
C. Provide the least important information first: This approach is not recommended because it does not prioritize the client's understanding of essential preoperative instructions.
D. Provide handouts written in the client's primary language: Correct. Providing written materials in the client's primary language allows them to review the information at their own pace and increases the likelihood of understanding important preoperative instructions.
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