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?
Hyperthermia
Urticaria
Dyspnea
Headache
The Correct Answer is C
Rationale:
A. Hyperthermia may indicate a transfusion reaction, but dyspnea is a more immediate concern.
B. Urticaria may indicate a mild allergic reaction, but dyspnea is a more immediate concern.
C. Dyspnea is a sign of a possible transfusion reaction and should be reported immediately to the provider.
D. A headache may indicate a mild reaction to the blood transfusion, but dyspnea is a more immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Rapid chewing is not a manifestation of dysphagia.
B. Increased hunger is not a manifestation of dysphagia.
C. A garbled voice can be a manifestation of dysphagia, as it may indicate difficulty swallowing or speaking.
D. Sneezing is not a manifestation of dysphagia.
Correct Answer is B
Explanation
Rationale:
A. Using the incentive spirometer is important for preventing atelectasis, but it does not prevent orthostatic hypotension.
B. Dangling the legs over the side of the bed before standing helps reduce the risk of orthostatic hypotension by allowing the body to gradually adjust to the change in position.
C. Increasing protein intake is important for wound healing and tissue repair, but it does not prevent orthostatic hypotension.
D. Performing regular isometric exercises is important for maintaining muscle strength and mobility, but it does not prevent orthostatic hypotension.
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