The nurse is caring for a patient receiving packed red blood cells which started at 11:30 AM. The patient's vital signs and assessment findings are provided in the table below. What type of transfusion reaction will the nurse identify that the patient is experiencing?

Acute hemolytic

Allergic

Anaphylactic

Circulatory overload

Answer and Explanation

The Correct Answer is B

Choice A reason: Acute hemolytic reactions are severe and typically present with symptoms such as fever, chills, flank pain, hemoglobinuria, and shock. The patient's mild symptoms of itching and a localized rash do not match the severe presentation of an acute hemolytic reaction.

Choice B reason: Allergic reactions to blood transfusions are common and usually present with symptoms such as itching, hives, and localized rash. The patient's vital signs and physical assessment showing mild itching and a rash on the arms are consistent with an allergic reaction.

Choice C reason: Anaphylactic reactions are severe allergic reactions that involve respiratory distress, hypotension, and shock. The patient's mild symptoms do not indicate an anaphylactic reaction.

Choice D reason: Circulatory overload presents with symptoms such as dyspnea, orthopnea, hypertension, and pulmonary edema. The patient's symptoms of itching and a rash do not align with circulatory overload.

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

Explanation

Choice A reason: Eating any foods before dialysis as long as fluid intake is limited is incorrect. Patients undergoing hemodialysis need to follow specific dietary restrictions to manage electrolyte balance and prevent complications. A renal diet typically limits potassium, phosphorus, and sodium intake, in addition to fluid restrictions.

Choice B reason: Reporting any unusual changes in the access site, like redness or swelling, is correct. Changes at the access site can indicate infection or other complications and require immediate attention.

Choice C reason: Checking blood pressure regularly to monitor for changes during dialysis is correct. Blood pressure monitoring is essential during dialysis to detect hypotension or hypertension and adjust treatment accordingly.

Choice D reason: Contacting the healthcare provider if swelling in hands, feet, or ankles is noticed is correct. Swelling can indicate fluid overload or other complications that need to be addressed.

Choice E reason: Understanding that hemodialysis will permanently cure kidney disease is incorrect. Hemodialysis is a treatment that replaces kidney function but does not cure kidney disease. It manages symptoms and removes waste products from the blood.

A. Kussmaul breathing B. Abdominal pain C. Positive Trousseau sign D. Decreased heart rate E. Confusion

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Kussmaul breathing is a deep, labored breathing pattern that is a compensatory mechanism for metabolic acidosis, commonly seen in diabetic ketoacidosis.

Choice B reason: Abdominal pain is a common symptom in diabetic ketoacidosis due to the metabolic disturbances and dehydration.

Choice C reason: A positive Trousseau sign is associated with hypocalcemia and is not a common manifestation of diabetic ketoacidosis.

Choice D reason: Decreased heart rate is not typical in diabetic ketoacidosis. In fact, patients might present with an increased heart rate due to dehydration and acidosis.

Choice E reason: Confusion is a symptom of diabetic ketoacidosis due to the effects of severe hyperglycemia and metabolic acidosis on the brain.

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The nurse is caring for a patient receiving packed red blood cells which started at 11:30 AM. The patient's vital signs and assessment findings are provided in the table below. What type of transfusion reaction will the nurse identify that the patient is experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a patient who is scheduled for hemodialysis about the process and potential complications. Which of the following statements by the patient indicates to the nurse the need for further teaching? (Select All That Apply)

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

Explanation

The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse is caring for a patient with metabolic alkalosis. What will the nurse recognize as the common cause of this acid-base imbalance?

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