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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Providing teaching without expecting the client to respond does not facilitate communication or ensure the client understands the information. The goal is to enhance communication, not to bypass it.
B. Speaking with a loud voice is unnecessary and can be counterproductive. Expressive aphasia affects the client’s ability to express themselves, not their hearing. Speaking loudly will not improve the client's ability to understand or communicate.
C. Avoiding facial gestures is not recommended. Non-verbal communication, such as facial expressions and gestures, can be valuable in helping the client understand the information being conveyed.
D. Determining the client’s ability to use a communication board is the most appropriate action. A communication board can help the client express their needs and understand instructions more effectively, making it a valuable tool for reinforcing teaching in clients with expressive aphasia.
Correct Answer is ["A","B","E","F"]
Explanation
A. The use of separate cutting boards for raw meats and vegetables is a fundamental food safety practice to prevent cross-contamination. On Day 14, the client demonstrates an
understanding of this by using one cutting board for raw meats and a different one for vegetables.
B. Increasing the handwashing time from 10 seconds to 15 seconds is in line with food safety guidelines, which recommend washing hands for at least 20 seconds to effectively remove germs.
C. Additionally, there was no information provided on the time leftovers sat unrefrigerated on the countertop, which should be minimized to prevent bacterial growth.
D. The client did not demonstrate an understanding of safe refrigerator temperatures as the temperature did not meet the recommended setting of 4° C (40° F) or below.
E. Defrosting frozen foods in the refrigerator is a safe practice to prevent the growth of harmful bacteria, which can occur when foods are defrosted on the countertop.
F. Discarding leftovers after 2 days minimizes the risk of foodborne illnesses, as the longer food is stored, even in the refrigerator, the higher the risk of bacterial growth.
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