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
Dyspnea
Hyperthermia
Urticaria
The Correct Answer is B
A. Headache can be a common side effect of blood transfusion but is not typically considered an urgent or life-threatening complication requiring immediate reporting.
B. Dyspnea (difficulty breathing) can indicate a serious transfusion reaction such as transfusion- related acute lung injury (TRALI) or circulatory overload and should be reported immediately to the provider for further evaluation and intervention.
C. Hyperthermia (elevated body temperature) may indicate a febrile reaction to the transfusion but is not as immediately life-threatening as dyspnea.
D. Urticaria (hives) is a common allergic reaction to blood transfusion but is not typically considered as urgent or life-threatening as dyspnea.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response acknowledges the client's decision and expresses concern for their well-being and the potential impact on their loved ones. It also opens the door for the client to discuss their decision-making process and receive support in communicating their decision to others.
B. This response may be perceived as judgmental or dismissive of the client's autonomy and decision-making capacity. It does not provide support or address the client's emotional or psychosocial needs.
C. Delaying the discussion may leave the client feeling unsupported or uncertain about their
decision. It's important to address the client's concerns and provide support in a timely manner.
D. This response minimizes the client's concerns and does not offer support or encouragement for discussing their decision with loved ones. It may also convey a lack of empathy or
understanding of the client's situation.
Correct Answer is B
Explanation
A. While repositioning is important for comfort and preventing pressure ulcers, repositioning every 4 hours may not be sufficient, and it does not directly address the client's dyspnea.
B. Circulating air with a fan can help reduce the sensation of breathlessness and improve comfort for clients experiencing dyspnea. This non-invasive measure can be effective in relieving symptoms.
C. Placing the head of the bed flat is generally not recommended for clients with dyspnea, as it can worsen breathing difficulties. Elevating the head of the bed is usually more helpful.
D. Frequent oral care is important for maintaining comfort, especially in end-of-life care, but every 8 hours might not be sufficient. More frequent oral care is typically needed, and while important, this does not directly address dyspnea.
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