A nurse is collecting data on a client who is receiving a unit of PRBCs. Which of the following findings is a manifestation of an allergic transfusion reaction?

Flank pain

Elevated blood pressure

Distended neck veins

Wheezing

Answer and Explanation

The Correct Answer is D

Choice A reason: Flank pain is not a sign of an allergic transfusion reaction. Flank pain is a pain in the side of the abdomen or back, usually caused by kidney problems, such as infection, stones, or injury. Flank pain can be a sign of a hemolytic transfusion reaction, which is a serious complication that occurs when the donor blood is incompatible with the recipient's blood type.

Choice B reason: Elevated blood pressure is not a sign of an allergic transfusion reaction. Elevated blood pressure is a condition where the force of the blood against the artery walls is too high, which can increase the risk of heart disease, stroke, and kidney damage. Elevated blood pressure can be a sign of a hypertensive transfusion reaction, which is a rare complication that occurs when the donor blood has a higher sodium level than the recipient's blood.

Choice C reason: Distended neck veins are not a sign of an allergic transfusion reaction. Distended neck veins are a sign of increased pressure in the right side of the heart or the superior vena cava, which can be caused by heart failure, pulmonary hypertension, or obstruction. Distended neck veins can be a sign of a circulatory overload transfusion reaction, which is a complication that occurs when the blood volume or rate of infusion is too high for the recipient's cardiovascular system.

Choice D reason: Wheezing is a sign of an allergic transfusion reaction. Wheezing is a high-pitched whistling sound that occurs when the airways are narrowed or inflamed, which can cause difficulty breathing, coughing, or chest tightness. Wheezing can be a sign of an allergic transfusion reaction, which is a hypersensitivity response to the donor blood or its components, such as plasma proteins, antibodies, or preservatives. An allergic transfusion reaction can range from mild to severe, and can be treated with antihistamines, corticosteroids, or epinephrine.

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Correct Answer is B

Explanation

Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.

Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.

Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.

Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.

A. Caffeinated beverages B. Low-fiber cereal C. White rice D. Ripe bananas

Correct Answer is A

Explanation

Choice A reason: Caffeinated beverages can cause diarrhea by stimulating the intestinal motility and increasing the fluid loss. They can also irritate the lining of the stomach and intestines.

Choice B reason: Low-fiber cereal is not likely to cause diarrhea. Fiber helps to bulk up the stool and regulate the bowel movements. Low-fiber foods are often recommended for clients with diarrhea to reduce intestinal activity.

Choice C reason: White rice is not likely to cause diarrhea. It is a bland and starchy food that can help to bind the stool and reduce fluid loss. White rice is often part of the BRAT diet (bananas, rice, applesauce, toast) that is suggested for clients with diarrhea.

Choice D reason: Ripe bananas are not likely to cause diarrhea. They are rich in potassium, which can help to replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help to firm up the stool.

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A nurse is collecting data on a client who is receiving a unit of PRBCs. Which of the following findings is a manifestation of an allergic transfusion reaction?

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