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

This statement shows that the client understands the importance of regularly checking the oxygen equipment for proper functioning and potential issues. Regular equipment checks help ensure the client's safety and effective oxygen therapy.

Adjusting the oxygen flow rate should be done based on the healthcare provider's instructions and not solely based on subjective feelings. The client should follow the prescribed flow rate and consult their healthcare provider if experiencing increased shortness of breath.

Isopropyl alcohol is not recommended for cleaning the nasal cannula as it can cause drying and irritation. The client should use mild soap and water for cleaning the nasal cannula as per the healthcare provider's instructions.

Synthetic blankets can generate static electricity, which could be a fire hazard in the presence of oxygen. The client should be advised to use cotton or wool blankets, which are non-flammable and safer with oxygen therapy.

A. “Music will distract my husband's awareness of the pain." B. “Playing music will increase my husband alertness." C. “My husband won't need medication for breakthrough pain while using music therapy." D. “I will discontinue music therapy when my husband is no longer responsive."

Correct Answer is A

Explanation

This statement demonstrates an understanding that music therapy can help divert the client's attention from the pain they are experiencing, providing a distraction and potentially reducing their awareness of the pain. Music therapy is often used as a complementary approach to pain management in hospice care, aiming to improve the client's comfort and well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

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