A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
Headache
Urticaria
Dyspnea
Hyperthermia
The Correct Answer is C
A. Headache: Headache can occur during a transfusion reaction but is usually a less urgent symptom. It should be monitored but is not the highest priority.
B. Urticaria: Urticaria (hives) often indicates a mild allergic reaction to the transfusion. It requires intervention but is generally not immediately life-threatening.
C. Dyspnea: Dyspnea signals possible respiratory distress, which may indicate a severe transfusion reaction such as anaphylaxis or transfusion-related acute lung injury (TRALI). This requires immediate attention and reporting to prevent respiratory failure.
D. Hyperthermia: A fever during transfusion suggests a febrile non-hemolytic reaction or infection risk, which is important but typically not as urgent as respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Interlock their fingers and hold their hands away from their body above their waist: This position maintains the sterility of the gloves by keeping the hands visible and above waist level, which is the accepted sterile field boundary.
B. Keep their arms at the sides of their body with their hands in a relaxed position: Keeping hands close to the body or at the sides risks contamination because the hands might touch nonsterile surfaces or the body, which is outside the sterile field.
C. Place one hand over the other against the part of the gown covering their upper body: Touching the gown, which is considered sterile only in the front above the waist, can risk contamination if hands move unexpectedly or if the gown surface is touched by nonsterile areas.
D. Clasp their hands together in a relaxed position behind their body at their waist: Positioning hands behind the back limits visibility and control over the sterile field, increasing the risk of contamination by touching nonsterile surfaces or moving out of the sterile boundary.
Correct Answer is D
Explanation
A. Impaired hearing: Impaired hearing can increase the risk of injury by reducing the client’s ability to hear alarms or warnings. However, it is considered a sensory impairment rather than a lifestyle choice.
B. Reduced health literacy: Low health literacy can contribute to poor understanding of safety instructions and adherence to precautions, increasing injury risk. Nonetheless, it relates more to knowledge deficits than lifestyle behaviors.
C. Lower extremity weakness: Weakness in the legs increases fall risk due to impaired mobility and balance. This is a physical or functional risk factor rather than a lifestyle risk.
D. Texting while driving: Texting while driving is a high-risk lifestyle behavior directly associated with increased injury and accident rates. It involves voluntary behavior that compromises safety and is a preventable cause of injury.
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