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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.

B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.

C. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.

D. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.

A. "Take a 1-hour nap each day." B. "Watch television in bed." C. "Take a long walk before bedtime." D. "Drink a glass of milk before bedtime."

Correct Answer is D

Explanation

A. Napping during the day may disrupt nighttime sleep patterns by reducing sleep drive.

B. Watching television in bed can stimulate the brain and interfere with sleep due to the blue light emitted from screens.
C. Engaging in vigorous physical activity close to bedtime may increase alertness and make it harder to fall asleep.

D. Drinking a glass of milk before bedtime can promote sleep due to the presence of tryptophan, which aids in the production of serotonin and melatonin, neurotransmitters involved in sleep
regulation.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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