The nurse is caring for a client receiving their second unit of Packed Red Blood Cells for an initial hemoglobin. The client appears flushed and complains of itching and urticaria. After following protocol (stopping transfusion, running 0.9% normal saline) and notifying the health care provider, the nurse would prepare to administer:
epinephrine 1mg IV.
acetaminophen 650mg PD.
diphenhydramine 50mg IV.
furosemide 40mg PO.
The Correct Answer is C
A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.
B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).
C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.
D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.
B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.
C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.
D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.
Correct Answer is A
Explanation
A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.
B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.
C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.
D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.
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