A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which data should the nurse recognize as an indication of a septic reaction to the blood transfusion?
Hypertension
Distended neck veins
Polyuria
Vomiting
The Correct Answer is D
Choice A reason: Hypertension is not a sign of a septic reaction, but rather a sign of a hypertensive or circulatory overload reaction to the blood transfusion.
Choice B reason: Distended neck veins are not a sign of a septic reaction, but rather a sign of a circulatory overload or cardiac failure reaction to the blood transfusion.
Choice C reason: Polyuria is not a sign of a septic reaction, but rather a sign of a hemolytic or renal failure reaction to the blood transfusion.
Choice D reason: Vomiting is a sign of a septic reaction, which occurs when the blood transfusion is contaminated with bacteria. Other signs of a septic reaction include fever, chills, hypotension, and shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Withholding the medication if the systolic blood pressure is less than 90 mm Hg is an appropriate action, as propranolol is a beta-blocker that can lower blood pressure and cause hypotension, which can impair tissue perfusion and cause dizziness, fainting, or shock.
Choice B reason: Requesting a dosage increase if the apical heart rate is less than 60/min is an inappropriate action, as propranolol can slow down the heart rate and cause bradycardia, which can lead to fatigue, weakness, or cardiac arrest. The nurse should monitor the apical pulse before administering propranolol and withhold it if it is less than 60/min.
Choice C reason: Informing the client to expect increased hair growth is an incorrect statement, as propranolol does not cause hypertrichosis or excessive hair growth. However, another beta-blocker, minoxidil, can cause this side effect.
Choice D reason: Administering the medication with an antacid is not an appropriate action, as antacids can interfere with the absorption of propranolol and reduce its effectiveness. The nurse should administer propranolol on an empty stomach or with food that does not contain antacids.
Correct Answer is B
Explanation
Choice A reason: Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter is a negative result for the tuberculin skin test, which means that the client does not have tuberculosis infection or exposure.
Choice B reason: Palpable area of induration, greater than 10 mm (0.4 in) in diameter is a positive result for the tuberculin skin test, which means that the client has tuberculosis infection or exposure and needs further testing, such as chest x-ray or sputum culture, to confirm the diagnosis and rule out active disease.
Choice C reason: Area of ecchymosis, greater than 12 mm (0.5 in) in diameter is not a relevant finding for the tuberculin skin test, as it indicates bruising or bleeding under the skin that may be caused by trauma or coagulation disorder.
Choice D reason: Tenderness at the injection site is not a relevant finding for the tuberculin skin test, as it indicates inflammation or irritation of the skin that may be caused by needle insertion or allergic reaction.
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