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
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.
Correct Answer is D
Explanation
A. Clients with expressive aphasia have difficulty expressing themselves verbally but can often understand spoken language. It's important for the nurse to provide the teaching without
expecting a verbal response from the client. The client may still benefit from receiving information even if they cannot verbally respond.
B. Speaking loudly is not helpful for clients with expressive aphasia and may increase confusion or frustration. The nurse should speak clearly and at a normal volume.
C. Facial gestures can aid in communication for clients with expressive aphasia by providing additional cues. The nurse should use facial expressions to enhance communication.
D.Clients with expressive aphasia have difficulty expressing themselves verbally. Assessing the client's ability to use alternative communication methods, such as a communication board, can help facilitate effective communication and understanding of the teaching.
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