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: Tumor in situ refers to a tumor that has not invaded surrounding tissues, which is not indicative of stage IV cancer.

Choice B reason: Stage IV cancer is characterized by distant metastasis, meaning the cancer has spread to other sites away from the primary location.

Choice C reason: While the spread into nearby tissues indicates progression, it does not necessarily mean stage IV unless there is distant metastasis.

Choice D reason: The presence of no abnormal cells would not be consistent with any stage of cancer.

A. Illusion B. Flashback C. Hallucination D. Delusion

Correct Answer is A

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus. Mr. S is mistaking the cracks in the plaster for snakes, which is an illusion.

Choice B reason: A flashback is a vivid memory of a traumatic event that feels like it is happening again. This does not describe Mr. S's experience.

Choice C reason: A hallucination is a sensory experience of something that does not exist outside the mind. Since Mr. S is misinterpreting an actual visual stimulus (the cracks), it is not a hallucination.

Choice D reason: A delusion is a firmly held false belief resistant to reason or confrontation with actual fact. Mr. S's belief is based on a misinterpretation of a visual stimulus, not a delusion.

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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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Naxlex Comprehensive Predictor Exams

The nurse is reading a patient's chart and notes the patient has a tumor stage of IV. Which describes the meaning of stage IV cancer?

Correct Answer is B

Explanation

Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:

Correct Answer is A

Explanation

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