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

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A) O- (O negative):
A person with blood type A- can safely receive blood from a universal donor blood type, which is O-. This is because O- has no A, B, or Rh antigens on the surface of its red blood cells, making it compatible with any ABO blood group. The Rh negative status is also compatible, as the recipient is also Rh-negative.

B) AB- (AB negative):
A person with blood type A- cannot receive blood from someone with AB-. This is because the AB- blood type contains both A and B antigens on the surface of red blood cells, which could cause an immune reaction in a person with A- blood, whose immune system will react against the B antigen. Therefore, AB- is not compatible with A- blood.

C) A+ (A positive):
A person with A- blood cannot receive blood from an A+ donor, because the A+ blood contains the Rh positive antigen. If a person with A- blood receives Rh-positive blood, they will form antibodies against the Rh factor, leading to a hemolytic transfusion reaction. Therefore, A+ is not compatible with A- blood.

D) A- (A negative):
A person with A- blood can receive blood from another A- donor, because both share the A antigen and are Rh-negative. This is a perfect match and poses no risk of a transfusion reaction.

E) O+ (O positive):
A person with A- blood cannot receive blood from an O+ donor, because the O+ blood contains the Rh-positive antigen. This could cause an immune reaction in a person with A- blood, leading to the production of anti-Rh antibodies. Therefore, O+ is not compatible with A- blood.

A. take this medication as needed for pain" B. stop the medication if experience dry mouth. C. taper this medication off over 1-2 weeks. D. feel an increase in energy with this medication.

Correct Answer is C

Explanation

A) Take this medication as needed for pain:
Baclofen is a muscle relaxant typically prescribed for managing spasticity associated with multiple sclerosis (MS), rather than for pain. It should be taken as prescribed, typically on a scheduled basis rather than on an as-needed basis for pain. Misunderstanding this could lead to improper use of the medication and ineffective symptom management.

B) Stop the medication if I experience dry mouth:
Dry mouth is a potential side effect of baclofen, but it should not be the reason to stop the medication abruptly. Stopping baclofen suddenly can result in withdrawal symptoms and could potentially worsen spasticity. If dry mouth or other side effects are bothersome, the client should consult the healthcare provider for management options rather than discontinuing the medication abruptly.

C) Taper this medication off over 1-2 weeks:
This statement demonstrates a correct understanding of the proper way to discontinue baclofen. Baclofen should not be stopped suddenly due to the risk of withdrawal symptoms, which can include increased spasticity, hallucinations, or seizures. A gradual tapering of the dose over a period of 1 to 2 weeks is recommended to avoid withdrawal. This is the most appropriate and safe response.

D) Feel an increase in energy with this medication:
Baclofen is not a medication designed to increase energy. Its primary purpose is to reduce muscle spasticity, not to provide a stimulant effect. If the client expects an increase in energy, this could indicate a misunderstanding of the medication's effects. Baclofen's focus is on reducing spasticity and muscle tightness, not improving energy levels.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).

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

Explanation

The nurse is providing education to the client diagnosed with multiple sclerosis (MS) about baclofen. What statement made by the client would indicate to the nurse that the client understood the education? The client states ‘’I will

Correct Answer is C

Explanation

A client in the gynecology clinic asks the nurse, ‘’What are the risk factors for developing cervical cancer?’’ Which statement by the nurse is the best response?

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

The nurse knows which of the following types of angina is most closely related with an impending myocardial infarction (MI)?

A client with an acute stroke must receive Alteplase 0.9 mg/kg. The client weighs 220 pounds. How should the client receive? (Round to the nearest whole number, do not use trailing zeros)

The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (SELECT ALL THAT APPLY)