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: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.

Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.

Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.

Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.

A. Thinking/content of thought B. Mood and affect C. Judgment D. Perception

Correct Answer is D

Explanation

Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.

Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.

Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.

Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.

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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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Explanation

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