The nurse is monitoring a patient receiving a blood transfusion. For Which symptoms would the nurse stop the transfusion but NOT administer 0,9% normal saline?
dyspnea, crackles, hypertension, and edema
low back pain, hypotension, and tachycardia
urticaria, itching, wheezing, angioedema
chest tightness, fever, chills/rigors
The Correct Answer is A
A) Dyspnea, crackles, hypertension, and edema:
These symptoms suggest a transfusion-related acute lung injury (TRALI) or circulatory overload (TACO), both of which are potentially life-threatening conditions. In cases of TRALI or TACO, the nurse should stop the transfusion immediately but should NOT administer 0.9% normal saline because saline could exacerbate fluid overload and worsen pulmonary edema. Instead, the nurse should focus on managing respiratory distress, ensuring proper oxygenation, and notifying the healthcare provider for further intervention.
B) Low back pain, hypotension, and tachycardia:
These symptoms are typically indicative of a hemolytic transfusion reaction (HTR), which requires immediate intervention. In this case, the transfusion should be stopped immediately, but the nurse should begin administering 0.9% normal saline to help maintain the patient's blood pressure and promote kidney perfusion to prevent renal damage.
C) Urticaria, itching, wheezing, angioedema:
These symptoms are characteristic of a mild allergic reaction to the blood transfusion. In this case, the nurse should stop the transfusion and administer 0.9% normal saline to maintain the patient’s hydration and blood pressure while managing the allergic reaction. The healthcare provider may order antihistamines or corticosteroids to treat the allergic symptoms.
D) Chest tightness, fever, chills/rigors:
These are common symptoms of a febrile non-hemolytic transfusion reaction (FNHTR), which is generally not life-threatening. The nurse should stop the transfusion but can continue administering 0.9% normal saline to support hydration and circulation. FNHTR is often managed with antipyretics (e.g., acetaminophen) to reduce fever and chills, and the transfusion may be resumed if symptoms resolve
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["13.7"]
Explanation
Given:
Ordered dose of Furosemide: 1 mg/kg
Patient weight: 121 lbs
Concentration of Furosemide: 40 mg/10 mL (4 mg/mL)
Step 1: Convert patient weight from pounds to kilograms:
1 pound (lb) = 0.453592 kilograms (kg)
Patient weight in kg = 121 lbs x 0.453592 kg/lb = 54.877832 kg
Step 2: Calculate the total dose of Furosemide:
Total dose (mg) = Ordered dose (mg/kg) x Patient weight (kg)
Total dose (mg) = 1 mg/kg x 54.877832 kg
Total dose (mg) = 54.877832 mg
Step 3: Calculate the volume to be administered:
Volume (mL) = Total dose (mg) / Concentration (mg/mL)
Volume (mL) = 54.877832 mg / 4 mg/mL
Volume (mL) = 13.719458 mL
Step 4: Round to the nearest tenth:
Volume (mL) ≈ 13.7 mL
Correct Answer is D
Explanation
A) Respiratory acidosis:
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood, leading to a decrease in pH. In the given blood gas values, the PaCO2 is 28 mmHg, which is lower than the normal range (35-45 mmHg), indicating that CO2 is being exhaled more than usual, not accumulating.
B) Metabolic acidosis:
Metabolic acidosis results from a decrease in bicarbonate (HCO3-) or an increase in acid in the body. However, in the provided values, the bicarbonate (HCO3-) is normal at 24 mEq/L, and the pH is elevated at 7.51, indicating alkalosis rather than acidosis
C) Metabolic alkalosis:
Metabolic alkalosis occurs when there is an increase in bicarbonate levels or excessive loss of acids, often associated with vomiting or diuretic use. However, in this case, the bicarbonate level (HCO3-) is normal, and the pH is more consistent with alkalosis due to respiratory factors, not metabolic causes.
D) Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a rise in blood pH (alkalosis). The pH is 7.51, which is above the normal range (7.35-7.45), indicating alkalosis. Additionally, the PaCO2 is low at 28 mmHg, which suggests that the client is hyperventilating and exhaling too much CO2, confirming respiratory alkalosis as the correct interpretation.
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