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.

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Correct Answer is B

Explanation

Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.

A. Choose a room that is well lit. B. Sit on the client's right side. C. Ask a few questions at a time. D. Exaggerate lip movement while speaking.

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. The nurse should choose a room that is well-lit, sit facing the client, speak clearly and slowly, and ask a few questions at a time. Exaggerating lip movement while speaking is not recommended as it can be difficult for the client to read lips accurately. Additionally, sitting on the client's right side may not make a significant difference in their ability to hear.

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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?

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Naxlex Comprehensive Predictor Exams

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