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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: This is incorrect because weight loss is not the highest priority finding for the nurse to report to the provider. Weight loss can be a common symptom of leukemia due to decreased appetite, increased metabolism, or malabsorption.

Choice B: This is incorrect because fatigue is not the highest priority finding for the nurse to report to the provider. Fatigue can be a common symptom of leukemia due to anemia, infection, or poor nutrition.

Choice C: This is incorrect because dysuria is not the highest priority finding for the nurse to report to the provider. Dysuria can indicate a urinary tract infection, which can be treated with antibiotics and fluids.

Choice D: This is correct because elevated temperature is the highest priority finding for the nurse to report to the provider. Elevated temperature can indicate a serious infection, which can be life-threatening for a client who has leukemia and a compromised immune system.

A. Provide the client with small-handled adaptive utensils. B. Describe the food placement as though the plate were a clock. C. Discourage conversations during the client's mealtime. D. Arrange for an assistive personnel to feed the client.

Correct Answer is B

Explanation

Choice A reason: Providing the client with small-handled adaptive utensils is not necessary for a visually impaired client. The client may prefer to use their own utensils or regular ones that they are familiar with.

Choice B reason: Describing the food placement as though the plate were a clock is a helpful technique to orient the client to their meal and avoid spills or accidents. The nurse should also ask the client about their preferences and needs before serving the food.

Choice C reason: Discouraging conversations during the client's mealtime is not appropriate for a visually impaired client. The nurse should encourage social interactions and respect the client's dignity and autonomy.

Choice D reason: Arranging for an assistive personnel to feed the client is not indicated for a visually impaired client. The nurse should promote the client's independence and self-care abilities as much as possible.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has leukemia. Which of the following findings is the highest priority for the nurse to report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

Correct Answer is B

Explanation

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