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: While individuals with obsessive-compulsive personality disorder may seek advice, it is not typically to an excessive amount, and this does not capture the essence of the disorder.

Choice B reason: Using physical appearance to gain attention is not a characteristic of obsessive-compulsive personality disorder; it is more associated with histrionic personality disorder.

Choice C reason: Being preoccupied with order and following rigid rules is a core feature of obsessive-compulsive personality disorder, reflecting a need for control and perfectionism.

Choice D reason: Believing one's achievements are superior to others is indicative of narcissistic personality disorder, not obsessive-compulsive personality disorder.

A. "I start to use the incentive spirometer when I can get out of bed." B. "I breathe deeply and cough every 4 hours." C. "I splint my incision with a pillow to cough." D. "I lie flat in bed to cough and deep breathe."

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.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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