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 B
Explanation
Choice a is not correct because consuming canned sardines twice a week is not a risk factor for osteoporosis, but rather a protective factor. Canned sardines are rich in calcium and vitamin D, which are essential for bone health.
Choice c is not correct because applying an estrogen vaginal cream daily is not a risk factor for osteoporosis, but rather a treatment option. Estrogen therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women.
Choice d is not correct because walking 30 minutes per day is not a risk factor for osteoporosis, but rather a beneficial exercise. Weight-bearing physical activity can stimulate bone formation and improve bone strength.
Correct Answer is A
Explanation
Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.
Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.
Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.
Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42
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