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 ["A","B","C","D","E"]
Explanation
In the scenario provided, the nurse should take further action based on the following findings: The client's distended abdomen, reports of nausea, and coughing suggest possible intolerance to the tube feedings or another complication. A gastric residual volume of 550 mL is significantly higher than the standard safe limit of 500 mL, indicating delayed gastric emptying or feeding intolerance. The pH of gastric aspirate at 4.5 is within normal limits, suggesting that the tube is likely placed correctly. However, the elevated heart rate of 110/min could be a response to discomfort or underlying stress. The pulse oximetry reading of 90% on room air is below the normal range, which typically is 95-100%, indicating potential impaired gas exchange or early signs of respiratory distress. These findings warrant immediate nursing interventions and possibly a reassessment of the feeding regimen, along with measures to improve the client's respiratory function and comfort. It is essential to monitor for further signs of aspiration, respiratory distress, or other complications, and to communicate these findings to the healthcare team for appropriate management.
Correct Answer is A
Explanation
A. BMI of 29 falls within the overweight range, which is typically defined as a BMI between 25 and 29.9.
B. A BMI of 29 does not fall within the ideal body weight range, which is typically considered to be between 18.5 and 24.9.
C. Obesity is typically classified as a BMI of 30 or higher. While a BMI of 29 is close to the obese range, it falls within the overweight category.
D. A BMI of 29 does not fall within the underweight range, which is typically considered to be a BMI below 18.5.
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