A client is receiving a blood transfusion, The nurse observes that the client is experiencing flank and lower back pain. Which of the following orders does the nurse anticipate receiving?

Intramuscular epinephrine

Intravenous corticosteroids

High volume IV fluids

PO diphenhydramine

Answer and Explanation

The Correct Answer is C

A. Intramuscular epinephrine:
Intramuscular epinephrine is typically used in cases of anaphylactic reactions, which present with symptoms such as difficulty breathing, swelling, hives, and hypotension. Flank and lower back pain are not typical signs of an anaphylactic reaction during a blood transfusion. Instead, flank pain may suggest a hemolytic reaction, which involves the destruction of red blood cells, not an allergic or anaphylactic response. Thus, epinephrine would not be the first-line treatment for this situation.

B. Intravenous corticosteroids:
Intravenous corticosteroids are often used for inflammatory reactions, such as in cases of autoimmune diseases or severe allergic reactions. While corticosteroids might be used for certain types of transfusion reactions, they are not the primary treatment for hemolytic reactions (which could cause flank and lower back pain). The primary goal in a transfusion reaction with flank pain is to manage potential hemolysis and prevent kidney damage, which would be addressed through hydration and other supportive measures.

C. High volume IV fluids:
High-volume IV fluids are the most appropriate immediate intervention for a client who is experiencing flank and lower back pain during a blood transfusion, which are signs of a potential hemolytic reaction. Hemolysis, or the breakdown of red blood cells, can lead to kidney injury, so increasing fluid volume helps flush the kidneys, promote diuresis, and reduce the risk of kidney damage. The fluids also help to dilute any hemoglobin that is released into the bloodstream, supporting the kidneys' ability to filter it out. This is the priority intervention in this scenario.

D. PO diphenhydramine:
Oral diphenhydramine is used for allergic reactions, such as mild reactions involving itching, rashes, or hives, but it is not appropriate for managing more severe transfusion reactions, such as hemolytic reactions, that cause flank and lower back pain. Diphenhydramine would not address the underlying issue of potential hemolysis and kidney injury. Therefore, it is not the correct intervention for this situation.

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Correct Answer is A

Explanation

A) Wear a HEPA/N95 mask while providing care to the client:
Tuberculosis (TB) is a highly contagious airborne disease, and healthcare workers caring for patients with active TB must wear a HEPA/N95 mask to protect themselves from inhaling the bacteria. These specialized masks filter out airborne particles, including Mycobacterium tuberculosis, which can be spread through droplets when the patient coughs, sneezes, or talks. Wearing an N95 mask is an essential part of airborne precautions in the care of TB patients.

B) Instruct the nursing assistant to wear a surgical mask when entering the client's room:
A surgical mask does not offer adequate protection against airborne pathogens like the tuberculosis bacteria. While surgical masks can block large droplets, they do not filter out smaller, airborne particles, such as those from TB. N95/HEPA masks are necessary for anyone entering the room of a patient with active tuberculosis, including nursing assistants, to ensure they are protected from inhaling infectious particles.

C) Ensure the client is in a positive pressure room:
A positive pressure room is typically used for patients who are immunocompromised, such as those with neutropenia or undergoing organ transplants, to prevent infection from the environment. However, negative pressure rooms are required for patients with airborne diseases like tuberculosis. A negative pressure room ensures that air flows into the room but does not leave, containing any airborne pathogens and preventing their spread to other areas of the facility.

D) Have the client wear a HEPA/N95 mask when outside of their room:
If the client with active tuberculosis needs to leave their room for medical procedures or testing, they should wear a HEPA/N95 mask to prevent spreading the bacteria to others through airborne transmission. This helps limit exposure to other individuals, as TB can be transmitted by airborne particles.

A. Diarrhea, possibly containing blood. B. Increased risk for colorectal cancer. C. Skip lesions and cobblestone appearance D. Risk for bowel perforation and toxic megacolon

Correct Answer is C

Explanation

A) Diarrhoea, possibly containing blood: Diarrhea, often accompanied by blood, is a hallmark symptom of ulcerative colitis. The inflammation typically starts in the rectum and extends proximally, causing frequent, bloody diarrhea. This symptom is a defining characteristic of the condition and is indicative of active disease.

B) Increased risk for colorectal cancer: Ulcerative colitis, especially when it is chronic or poorly controlled, significantly increases the risk for colorectal cancer. This is due to long-term inflammation that can cause cellular changes in the colon over time. Regular screenings are recommended for individuals with a history of ulcerative colitis.

C) Skip lesions and cobblestone appearance: This is the exception. Skip lesions and a cobblestone appearance are characteristic of Crohn's disease, not ulcerative colitis. Crohn's disease can affect any part of the gastrointestinal tract and often exhibits areas of healthy tissue interspersed with areas of inflammation, known as skip lesions. Ulcerative colitis, in contrast, involves continuous inflammation that typically starts in the rectum and progresses proximally without the skip pattern.

D) Risk for bowel perforation and toxic megacolon: Both bowel perforation and toxic megacolon are complications associated with ulcerative colitis, particularly during severe flare-ups. Toxic megacolon is a life-threatening condition where the colon becomes massively dilated and can rupture, leading to peritonitis. This is a known risk with severe or poorly managed ulcerative colitis.

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A client is receiving a blood transfusion, The nurse observes that the client is experiencing flank and lower back pain. Which of the following orders does the nurse anticipate receiving?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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