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 B

Explanation

Choice A reason: Notifying the registered nurse is important but should come after initially assessing the patient's immediate needs.

Choice B reason: Raising the head of the bed may help with breathing but does not address the cause of the patient's distress.

Choice C reason: Sitting with her and listening to her concerns is supportive but should follow an initial assessment of why she is sobbing and gasping for breath.

Choice D reason: Asking the patient what is wrong is the first step in assessing the situation and providing appropriate care.

A. Protecting the client from self-harm behavior. B. Providing strategies for redirecting violent behavior. C. Exploring reasons for her behavior. D. Encouraging the client to talk about her feelings.

Correct Answer is A

Explanation

Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.

Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.

Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.

Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.

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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?

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