A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?
Temperature 38.8° C (101.8° F)
Straw-colored urine
Apical pulse rate 58/min
Blood pressure 158/92 mm Hg
The Correct Answer is A
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.
No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.
Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.
Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.
Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.
Correct Answer is A
Explanation
The normal range for potassium levels is generally between 3.5 to 5.0 mEq/L. A potassium level of 3.5 mEq/L falls within the lower end of the normal range, suggesting that the client's potassium levels are relatively stable. This finding alone does not indicate the overall effectiveness of the behavioral plan.
The normal range for sodium levels is typically between 135 to 145 mEq/L. A sodium level of 130 mEq/L falls below the normal range and indicates hyponatremia (low sodium levels). Hyponatremia can be a cause for concern, and it suggests that the behavioral management plan may need further attention or adjustments.
The normal range for hemoglobin (Hgb) levels varies depending on factors such as age and gender. However, in general, a Hgb level of 10 g/dL falls below the normal range and indicates anemia. Anemia is a common complication in individuals with anorexia nervosa and can result from inadequate nutrient intake. This finding suggests that the behavioral plan may need further evaluation and adjustment to address the client's nutritional needs.
Body Mass Index (BMI) is a measure that relates weight and height. A BMI of 14.5 indicates severe underweight and is well below the normal range. This finding suggests that the client's nutritional status is still significantly compromised, and the behavioral management plan may require further attention to support weight restoration and overall recovery.
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