A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Client report of intense feeling of heat in the fingers

Pallor of the toes with cold exposure

Feet that become reddened with ambulation

Swelling of the joints of the fingers

Answer and Explanation

The Correct Answer is B

A.   This is not typical for Raynaud's phenomenon. Instead, Raynaud's is characterized by episodes of reduced blood flow to the extremities, often triggered by cold or stress, leading to sensations of coldness or numbness rather than warmth.
B.   This finding aligns with Raynaud's phenomenon. During an episode, the blood vessels constrict in response to cold or stress, leading to pallor (whiteness) in the affected areas, such as the toes and fingers. This is a classic symptom of the condition.
C.   While feet can become reddened due to increased blood flow after rewarming or after exposure to warmth, this is not a characteristic feature of Raynaud's phenomenon. In Raynaud's, the affected areas typically exhibit color changes from white (pallor) to blue (cyanosis) and then red (hyperemia) as blood flow returns, but redness upon ambulation is not specifically indicative of the phenomenon.
D.   Swelling of the joints can occur in SLE due to arthritis or inflammation but is not a direct symptom of Raynaud's phenomenon. Raynaud's primarily affects blood flow and does not inherently cause joint swelling; however, a client with SLE may experience joint symptoms due to other underlying inflammatory processes.

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Correct Answer is A

Explanation

A. Morphine is a strong opioid analgesic that is effective for managing severe pain, especially in acute situations like a vaso-occlusive crisis. Administering it intravenously allows for rapid onset of pain relief, which is critical given the severity of the patient’s symptoms. Continuous dosing (ATC—around the clock) ensures that pain is managed effectively.
B. Fentanyl patches are typically used for chronic pain management and take time to reach effective levels in the bloodstream (up to 12 hours or longer). In the case of acute severe pain from a vaso- occlusive crisis, this option would not provide immediate relief.
C. While ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help relieve mild to moderate pain, it is not adequate for severe pain management. Additionally, in the setting of sickle cell disease, patients may be at risk for renal issues, making high doses of NSAIDs potentially harmful.
D. Hydromorphone is also a strong opioid analgesic; however, administering it orally may not be effective for severe pain management in an acute situation. IV administration of opioids is preferred for immediate and potent pain relief during a vaso-occlusive crisis.

A. Ensure that patients with AB+ blood type only receive blood from AB type donors B. Finish transfusing PRBC's within 2 hours C. Remain with the patient during the first 15 minutes of the infusion D. Double check the blood product against the patient blood band with another RN E. Prime blood tubing with normal saline (NS)

Correct Answer is ["B","C","D","E"]

Explanation

A. Individuals with AB+ blood type can receive blood from any donor type (A, B, AB, or O) because they have no antibodies against A or B antigens. The safest practice is to provide the most compatible blood type, but AB+ recipients are considered universal recipients.
B. To minimize the risk of bacterial growth and transfusion reactions, packed red blood cells (PRBCs) should be transfused within 2 hours of starting the infusion. It’s important to monitor the patient closely during this time.
C. The first 15 minutes of a blood transfusion are critical for observing any immediate adverse reactions. The nurse should stay with the patient during this time to monitor vital signs and assess for any signs of a transfusion reaction.
D. A crucial safety step is to verify the blood product against the patient’s blood band with another registered nurse (RN). This helps prevent errors related to mismatched blood transfusions, which can be life-threatening.
E. Blood transfusion tubing should be primed with normal saline to ensure that the blood product flows properly and to maintain patency. Normal saline is used because it is compatible with blood products and does not cause hemolysis.

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A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

You are planning on transfusing a unit of blood. Which of the following are appropriate measures to take? (Select all that apply)

Correct Answer is ["B","C","D","E"]

Explanation

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