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 C
Explanation
Choice A reason: WBC count 10,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate any infection or inflammation.
Choice B reason: BUN 20 mg/dL is within the normal range of 10 to 20 mg/dL and does not indicate any renal impairment or dehydration.
Choice C reason: Creatinine 2.3 mg/dL is above the normal range of 0.6 to 1.2 mg/dL and indicates renal dysfunction or damage, which can be caused by blood loss, hypotension, or nephrotoxic drugs during surgery. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.

Choice D reason: Hematocrit 41% is within the normal range of 37% to 47% for females and does not indicate any anemia or polycythemia.
Correct Answer is B
Explanation
Choice A reason: Blurred vision is not an expected side effect of digoxin, but a sign of digoxin toxicity, which requires immediate medical attention.
Choice B reason: This is the correct answer because digoxin can cause hypokalemia (low potassium levels), which increases the risk of digoxin toxicity. Therefore, clients taking digoxin need to have their potassium levels monitored regularly and consume foods rich in potassium.

Choice C reason: Antacids can interfere with the absorption of digoxin and reduce its effectiveness. Clients taking digoxin should avoid taking antacids within two hours of taking the medication.
Choice D reason: Weighing oneself every other day is not related to digoxin therapy, but to fluid balance. Clients with heart failure, who are often prescribed digoxin, need to monitor their weight daily and report any significant changes to their health care provider.
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