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. This response is judgmental and may cause the client to feel guilty or defensive.
B. This response shows empathy and respect for the client's decision.
C. This response may be appropriate if the client needs further information or counseling but should not be the initial response.
D. This response is confrontational and may cause the client to become defensive.
Correct Answer is D
Explanation
Rationale:
A. A fever may influence the result of an oxygen saturation test but is not a direct factor.
B. An elevated hemoglobin level is unlikely to influence the result of an oxygen saturation test.
C. Wearing a ring is unlikely to influence the result of an oxygen saturation test.
D. Wearing nail polish can interfere with the accuracy of pulse oximetry readings by causing an inaccurate reflection of light, leading to a falsely low oxygen saturation reading.
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