A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Vomiting

Urticaria

Low back pain

Pulmonary congestion

Answer and Explanation

The Correct Answer is C

Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.

Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.

Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.

Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.

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Correct Answer is C

Explanation

Choice A reason: Using the incentive spirometer is important, but it is not specifically related to deep breathing and coughing exercises.

Choice B reason: Breathing deeply and coughing every 4 hours is part of postoperative care, but it does not indicate understanding of the technique to protect the incision.

Choice C reason: Splinting the incision with a pillow while coughing is a recommended technique to support the incision and reduce pain during coughing, indicating an understanding of the instructions.

Choice D reason: Lying flat is not recommended for deep breathing and coughing exercises as it can inhibit lung expansion and is not conducive to effective coughing.

A. Forms new relationships easily B. Chemical dependency C. Feelings of low self-esteem D. Social integration E. Flashbacks F. Irritability

Correct Answer is ["B","C","E","F"]

Explanation

Choice A reason: Forming new relationships easily is not typically associated with PTSD.

Choice B reason: Chemical dependency can be a coping mechanism for those with PTSD.

Choice C reason: Feelings of low self-esteem are common in individuals with PTSD.

Choice D reason: Social integration is not a symptom of PTSD; rather, individuals may struggle with social interactions.

Choice E reason: Flashbacks are a hallmark symptom of PTSD, where individuals relive the traumatic event.

Choice F reason: Irritability is a common symptom of PTSD, often due to heightened arousal and anxiety.

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A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

Correct Answer is C

Explanation

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Correct Answer is ["B","C","E","F"]

Explanation

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