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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Avoiding alcoholic beverages late in the evening can help improve sleep quality. Alcohol can disrupt the sleep cycle and lead to fragmented sleep. For someone experiencing insomnia, avoiding alcohol close to bedtime can prevent further sleep disturbances and help maintain a more restful sleep.
Choice B reason: Taking the medication in the evening is not recommended for patients experiencing insomnia as a side effect of prednisone. Prednisone is a corticosteroid that can increase alertness and cause difficulty sleeping. It is typically recommended to take the medication in the morning to align with the body's natural cortisol production and minimize sleep disturbances.
Choice C reason: Doing a vigorous exercise routine right before bed is not advisable. While regular exercise can promote better sleep, vigorous physical activity close to bedtime can stimulate the body and make it harder to fall asleep. It is better to exercise earlier in the day and engage in relaxing activities before bed to prepare the body for sleep.
Choice D reason: Maintaining the same consistent sleep schedule is crucial for managing insomnia. Going to bed and waking up at the same time every day helps regulate the body's internal clock and improve sleep quality. Consistency in sleep routines can make it easier to fall asleep and wake up refreshed.
Choice E reason: Reading or doing another quiet, noncomputer activity before bed is a good recommendation for improving sleep. Engaging in calming activities such as reading a book, listening to soothing music, or practicing relaxation exercises can help prepare the mind and body for sleep. Avoiding screens and bright lights before bed is important as they can interfere with the production of melatonin, a hormone that regulates sleep.
Correct Answer is A
Explanation
Choice A reason: The lab results pH 7.30, PaCO2 59, HCO3 30 indicate respiratory acidosis with partial compensation. This is a typical finding in patients with chronic obstructive pulmonary disease (COPD) due to chronic hypoventilation and CO2 retention. The elevated PaCO2 reflects respiratory acidosis, and the elevated HCO3 indicates renal compensation to maintain acid-base balance.
Choice B reason: The lab results pH 7.50, PaCO2 30, HCO3 24 indicate respiratory alkalosis. This is not typical for COPD, where respiratory acidosis is more common.
Choice C reason: The lab results pH 7.48, PaCO2 42, HCO3 29 indicate metabolic alkalosis with partial compensation, which is not consistent with the primary respiratory issues seen in COPD.
Choice D reason: The lab results pH 7.33, PaCO2 34, HCO3 18 indicate metabolic acidosis with partial compensation, which is not typical for COPD. COPD primarily causes respiratory acidosis due to CO2 retention.
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