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 B
Explanation
Rationale:
A. Taking a 1-hour nap each day may disrupt the client's sleep-wake cycle and make it more difficult to sleep at night.
B. Drinking a glass of milk before bedtime can promote sleep because milk contains tryptophan, an amino acid that can help induce sleep.
C. Taking a long walk before bedtime may increase the client's energy level and make it more difficult to sleep.
D. Watching television in bed can disrupt the client's sleep-wake cycle and make it more difficult to sleep.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
A. Physical therapy for muscle-strengthening and balance-training is expected because the client has a left lateral malleolus fracture and a Bone Mineral Density DEXA scan of -3.8. Physical therapy can help with rehabilitation and prevent future falls.
B. Calcium supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Calcium supplementation is essential for bone health.
C. Vitamin D supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Vitamin D supplementation is essential for calcium absorption and bone health.
D. A home health evaluation of home safety is expected because the client lives alone and has a history of falling. A home health evaluation can help identify potential hazards and improve safety.
E. Increasing caffeine intake is unexpected because the client already reports consuming at least 3 cups of coffee daily. Increasing caffeine intake further may not be advisable due to potential side effects, such as increased heart rate and blood pressure.
F. Increasing daily sun exposure is unexpected because the client has osteoporosis and a history of falling. Excessive sun exposure can increase the risk of skin cancer, and the client may not be able to safely spend extended periods of time in the sun due to mobility limitations. Additionally, vitamin D supplementation is usually recommended over sun exposure for individuals with osteoporosis.
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