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. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.
B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.
C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.
D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.
Correct Answer is B
Explanation
A. Tortuous veins: Tortuous veins indicate varicosities, which are typically a chronic condition and not an immediate sign of deep-vein thrombosis (DVT). While they can be associated with venous insufficiency, they do not require urgent reporting for DVT suspicion.
B. Calf swelling: Calf swelling, especially if unilateral, is a classic sign of DVT and suggests venous obstruction by a thrombus. This finding requires prompt reporting to prevent complications such as pulmonary embolism.
C. Bradycardia: Bradycardia is unrelated to DVT and is not an expected finding in this condition. It does not indicate thrombotic complications and does not require immediate reporting in this context.
D. Clammy skin: Clammy skin can be a nonspecific sign related to many conditions such as shock or anxiety but is not a primary indicator of DVT. It does not necessitate urgent reporting for DVT unless accompanied by other concerning signs.
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