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: Taking ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause a false-positive result on a fecal occult blood screening test, as they can irritate the gastrointestinal mucosa and cause bleeding.
Choice B reason: Having a hemorrhoidectomy 1 year ago is unlikely to cause a false-positive result on a fecal occult blood screening test, as hemorrhoids are usually a source of bright red blood that can be seen with naked eye, not occult blood that requires chemical detection.
Choice C reason: Having a history of breast cancer is not related to a false-positive result on a fecal occult blood screening test, as breast cancer does not affect the gastrointestinal tract or cause bleeding in stool.
Choice D reason: Consuming citrus juice 3 days before the test is not likely to cause a false-positive result on a fecal occult blood screening test, as citrus juice does not contain any substances that can interfere with the chemical reaction of the test. However, consuming red meat, raw vegetables, vitamin C supplements, or iron supplements within 3 days before the test can cause false-negative results, as they can mask or degrade occult blood in stool.
Correct Answer is A
Explanation
Choice A: This is correct because aligning the client's joints with the joints on the frame can ensure proper functioning and comfort of the CPM device. The nurse should adjust the length and width of the device to fit the client's leg and secure it with straps.
Choice B: This is incorrect because padding the CPM device with a thick pillow can interfere with its movement and cause pressure on the leg. The nurse should use only thin padding or no padding at all for the CPM device.
Choice C: This is incorrect because placing the client in high-Fowler's position can cause flexion contractures and impair circulation in the leg. The nurse should place the client in supine or semi-Fowler's position with the leg elevated on pillows.
Choice D: This is incorrect because setting the degree of flexion and extension as tolerated by client can cause excessive pain and damage to the joint. The nurse should set the degree of flexion and extension according to the provider's prescription and gradually increase it as ordered.
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