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 C
Explanation
A nurse assisting with the care of a client who is 6 hours postoperative following a right total knee arthroplasty should check the client's pedal pulses every hour. This is important to assess the adequacy of blood flow and tissue perfusion to the extremity.
It is also important to monitor the client's pain level, administer pain medication as ordered, and encourage the client to perform exercises as appropriate.
The head of the client's bed should be maintained in a semi-Fowler's position to promote optimal respiratory function, and the client's dressing should be changed only as needed and with sterile technique.
An abductor wedge is not typically used following knee arthroplasty surgery.
Correct Answer is C
Explanation
Perpetrators of child abuse often exhibit rigid expectations of behavior, demanding strict adherence to rules and may have unrealistic or age-inappropriate expectations for their children. This can lead to increased stress and frustration, which may manifest in abusive behaviors.
Laissez-faire leadership style: A laissez-faire leadership style refers to a hands-off or
non-directive approach, where individuals allow others to make decisions and take control. While this leadership style may have its own implications, it is not specifically associated with child abuse.
Self-blame for financial problems: Self-blame for financial problems may indicate feelings of guilt or personal responsibility for economic difficulties. While financial stress can contribute to increased risk of child abuse, self-blame alone is not a characteristic specific to perpetrators of child abuse.
High self-esteem: High self-esteem refers to a positive self-regard and belief in one's abilities and worth. While low self-esteem can contribute to various psychological issues, including potential difficulties in parenting, high self-esteem is not a characteristic specifically associated with perpetrators of child abuse.
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