A nurse has initiated the infusion of packed RBCs through an 18-gauge peripheral IV to be administered over 2 hours. The client is experiencing symptoms of itching and anxiety, and presents with a flushed face and hives.
Complete the following sentence: “The client’s condition is indicative of _.”.

An allergic reaction

Normal side effects of the procedure

Anxiety disorder

Hypersensitivity to the IV gauge material .

Answer and Explanation

The Correct Answer is A

Choice A rationale

The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.

Choice B rationale

While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.

Choice C rationale

Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.

Choice D rationale

Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.

Nursing Test Bank

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Correct Answer is A

Explanation

The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.

A. 2 cups of soup B. 1 quart of water C. 8 oz of ice chips D. 6 oz of tea

Correct Answer is C

Explanation

Choice A rationale

A cup of soup is typically 240 mL, so 2 cups would be 480 mL, which is more than 120 mL1.

Choice B rationale

A quart is a unit of volume equal to 946 mL, which is significantly more than 120 mL1.

Choice C rationale

8 oz of ice chips is approximately equivalent to 120 mL2. This is because when ice melts, it reduces in volume by about half, so 8 oz of ice chips would melt to about 4 oz of water, which is approximately 120 mL2.

Choice D rationale

6 oz is approximately 177 mL, which is more than 120 mL2.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Correct Answer is A

Explanation

A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

Correct Answer is C

Explanation

A nurse in a clinic is caring for a middle-aged patient who states, “The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening.What does that involve?” Which of the following responses should the nurse make?

A client with herpes zoster is inquiring about the use of complementary and alternative therapies for pain management.Which therapy should the nurse inform the client is contraindicated for their condition?

A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

The client was admitted with a productive cough with thick yellow sputum.Breath sounds with crackles were heard in the left upper lobe and decreased breath sounds at bases bilaterally. What is the client’s temperature?

A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions. Exhibits Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:

A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which action should the nurse take?