A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg, and the physician diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension since the client denies any discomfort. What would be the nurse's best response?

"Hypertension is the leading cause of death in people your age."

"Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group."

"Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs."

"Hypertension greatly increases your risk of stroke and heart disease."

Answer and Explanation

The Correct Answer is D

A. "Hypertension is the leading cause of death in people your age.": While hypertension is a significant risk factor for cardiovascular events and mortality, stating it as the leading cause of death without specific context or statistical data may not provide the most informative response to the client's question.

B. "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group.": Hypertension is primarily associated with cardiovascular risks such as stroke, heart disease, and kidney disease. While it can contribute to overall health risks, it is not typically linked directly to type 1 diabetes or cancer in the context of this client's question.

C. "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs.": While hypertension can contribute to cardiovascular complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE), these are not the primary risks that are typically emphasized when discussing the importance of treating hypertension.

D. "Hypertension greatly increases your risk of stroke and heart disease.": This response is the most relevant and specific to the client's question. Hypertension is a major risk factor for stroke, heart disease (including heart attack and heart failure), and other cardiovascular complications. By treating hypertension and controlling blood pressure within recommended targets, the client can significantly reduce the risk of these serious and potentially life-threatening conditions.

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Correct Answer is D

Explanation

A. Remove the client's IV access:

Removing the client's IV access is not the most appropriate initial action when a client experiences difficulty breathing and severe chest tightness during a transfusion. While it's important to discontinue the infusion, the immediate priority is to stop the transfusion itself to prevent further reaction and assess the client's condition.

B. Assess the client's chest sounds and vital signs:

This choice is the correct answer. After stopping the transfusion, the nurse should assess the client's respiratory status by listening to chest sounds for any wheezing or crackles, as well as checking vital signs such as oxygen saturation, respiratory rate, blood pressure, and heart rate. These assessments help evaluate the severity of the reaction and guide further interventions.

C. Notify the client's healthcare provider:

Notifying the healthcare provider is an essential step, but it typically follows the immediate action of stopping the transfusion and assessing the client's condition. The healthcare provider needs to be informed promptly about the client's condition, transfusion reaction, and the actions taken for further guidance and orders.

D. Stop the transfusion immediately:

This is the initial and most critical action when a client experiences signs of a transfusion reaction such as difficulty breathing and severe chest tightness. Stopping the transfusion promptly helps prevent the reaction from worsening and allows for immediate assessment and intervention to ensure client safety.

A. The blood was infused too quickly and overwhelmed the client's circulatory system. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. Antibodies to donor leukocytes remained in the blood.

Correct Answer is B

Explanation

A. The blood was infused too quickly and overwhelmed the client's circulatory system:

While infusing blood too quickly can lead to circulatory overload and related complications like heart failure or pulmonary edema, it is not the cause of an acute hemolytic transfusion reaction. Acute hemolytic reactions occur due to immune responses against incompatible donor blood.

B. The donor blood was incompatible with that of the client:

This is the correct answer. An acute hemolytic transfusion reaction happens when there is an incompatibility between the donor's blood and the recipient's blood. This can occur due to mismatched ABO blood types or Rh factor, leading to the recipient's immune system attacking and destroying the transfused red blood cells.

C. The client had a sensitivity reaction to a plasma protein in the blood:

Sensitivity reactions to plasma proteins can occur, but they typically result in different types of transfusion reactions, such as allergic reactions or febrile non-hemolytic reactions. These reactions are caused by antibodies to specific plasma proteins and are not the cause of acute hemolytic transfusion reactions.

D. Antibodies to donor leukocytes remained in the blood:

This option refers to febrile non-hemolytic transfusion reactions, which occur due to antibodies against donor leukocytes. However, this type of reaction is distinct from acute hemolytic reactions, which are primarily caused by ABO or Rh incompatibility.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

Correct Answer is D

Explanation

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?

Correct Answer is B

Explanation

The nurse is caring for a client newly diagnosed with hypertension. Which statement by the client indicates the need for further teaching?

The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse most appropriate response

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by stating what?

A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client? (Select All that Apply.)

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

The nurse is caring for a client prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? (Select All that Apply.)

The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)