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A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Vital Signs 

0800: 

Blood pressure 112/64 mm Hg 

Heart rate 80/min 

Respiratory rate 18/min 

Temperature 37.1° C (98.8" F 

Oxygen saturation 97% on room air 

08151 

Blood pressure 106/54 mm Hg Heart rate 100/min 

Respiratory rate 22/min Temperature 37° C (98,6°F) 

Oxygen saturation 95% on room air

Complete the following sentence by using the lists of options.
The client has manifestations of

an , as evidenced by the

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase  in respiratory rate to 22 and the increase in heart rate from 88 to 100. 

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common  with blood transfusion.


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Related Questions

Correct Answer is C

Explanation

A: The client's statement reflects feelings of confusion but does not indicate immediate harm or danger to themselves. It requires therapeutic communication and support but not immediate action.
B: The client's statement expresses concern about their future relationships but does not indicate immediate harm or danger to themselves. It requires support and counseling but not immediate action.
C: Correct. The client's statement suggests significant emotional distress and a potential risk for self-harm or suicidal ideation. Immediate action is required to assess the client's safety and provide appropriate interventions, such as involving a mental health professional.
D: The client's statement indicates dissatisfaction or regret about the mastectomy decision but does not indicate immediate harm or danger to themselves. It requires supportive communication and addressing concerns but not immediate action.

Correct Answer is C

Explanation

A. Remove dentures:

  • Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.

B. Apply a shroud around the body with a visible identification tag:

  • Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.

C. Clean soiled areas of the body:

  • This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.

D. Place the client's head in a dependent position:

  • Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.

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