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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

As a nurse, the intervention that should be recommended is encouraging the client to take frequent walks during the day. This will help the client expend some energy and reduce the restlessness that could be causing the sleep disturbance at night.

The other options are not recommended because barbiturate medications can cause excessive sedation, allowing the client to nap for at least 1 hour during the day can interfere with their ability to sleep at night, and putting a lock on the client's door can be a safety risk in case of an emergency.

A. Clam chowder B. Pulled-pork sandwich C. Shrimp salad D. Roasted salmon

Correct Answer is D

Explanation

Kosher dietary laws prohibit the consumption of shellfish (such as clam chowder and shrimp salad) and pork (such as a pulled-pork sandwich). Therefore, the nurse should avoid including clam chowder, pulled-pork sandwich, and shrimp salad in the client's menu.

Instead, offering foods that comply with kosher guidelines, such as roasted salmon, ensures that the client's dietary needs and preferences are respected.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Correct Answer is D

Explanation

A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who is at 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron-deficiency anemia. Which of the following recommendations should the nurse make to improve the absorption of the medication?

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?