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

Answer and Explanation

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

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Correct Answer is B

Explanation

A) Treatment plan will need to be changed to achieve the desired effect:
The decrease in the carcinoembryonic antigen (CEA) levels from 50 ng/mL to 10 ng/mL suggests that the cancer is responding to the current treatment, not that the treatment plan needs to be changed. A drop in CEA levels typically indicates a positive response to treatment, such as chemotherapy, in reducing the number or size of cancer cells.

B) Cancer treatment is having the desired effect on killing cancer cells:
Carcinoembryonic antigen (CEA) is a tumor marker that is often elevated in individuals with certain cancers, particularly colorectal cancer. A decrease in CEA levels, as noted in this case (from 50 ng/mL to 10 ng/mL), usually signifies that the treatment is successfully targeting the cancer and reducing the tumor burden. This drop suggests that the chemotherapy is effectively killing cancer cells and reducing the size or activity of the tumor.

C) Client is at greater risk for tumor lysis syndrome:
Tumor lysis syndrome typically occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream, which can lead to metabolic disturbances like hyperkalemia, hyperphosphatemia, and renal failure. It is more common in aggressive hematologic cancers, such as leukemia or lymphoma, and typically presents with a rapid rise in tumor marker levels, not a decrease.

D) Cancer has increased size and metastatic sites:
An increase in tumor size or the development of metastatic sites would typically result in an increase in CEA levels, not a decrease. Since CEA levels have dropped, it is more likely that the cancer is shrinking or responding to the current treatment. This finding is more indicative of a positive response rather than disease progression.

A. Notify the primary care provides with increased urine output B. Assess daily for redness. swelling or exudate at insertion site weekly C. The primary care provider will monitor hemoglobin and a hematocrit values D. To maintain patency, the catheter should be flushed weekly using at 5ml syringe

Correct Answer is B

Explanation

A) Notify the primary care provider with increased urine output
Increased urine output is not directly related to signs or symptoms of infection associated with a tunneled IV catheter, such as a Hickman catheter. While changes in urinary output might indicate renal or other systemic issues, they do not signal a local infection at the insertion site.

B) Assess daily for redness, swelling, or exudate at insertion site weekly
One of the most common complications of a tunneled IV catheter, such as a Hickman, is infection at the insertion site or along the catheter tract. The nurse should instruct the patient to monitor for signs of infection, including redness, swelling, and exudate (pus or drainage) at the insertion site. These signs suggest possible infection, and early detection is critical to preventing more serious complications like sepsis.

C) The primary care provider will monitor hemoglobin and hematocrit values
While monitoring hemoglobin and hematocrit values is important for assessing overall health and blood status, it is not specifically related to monitoring for infection in a client with a tunneled IV catheter. Hemoglobin and hematocrit can provide information about anemia or dehydration but do not directly indicate an infection at the insertion site.

D) To maintain patency, the catheter should be flushed weekly using a 5ml syringe
Although flushing a tunneled IV catheter to maintain patency is important, this response does not directly address infection prevention, which is the focus of the question. Typically, a catheter should be flushed as per specific guidelines (which may include daily or weekly flushing, depending on the clinical setting).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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