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 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.
Correct Answer is ["B","D","E"]
Explanation
A. Room number: Room number is not a reliable client identifier because clients can be moved or rooms reassigned, which increases the risk of medication errors or misidentification.
B. Photo identification: Using photo identification is a reliable way to confirm the client’s identity, ensuring that medications are given to the correct person by visually matching the client’s face.
C. Diagnosis: Diagnosis alone is not a unique identifier since multiple clients can share the same diagnosis, and it does not confirm identity for medication administration purposes.
D. Facility-assigned identification number: This number is a unique identifier assigned to each client and is commonly used in healthcare settings to verify identity accurately before medication administration.
E. Date of birth: Date of birth is a reliable identifier to cross-check client identity, especially when used with other identifiers, reducing the risk of errors during medication administration.
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