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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Spinach is a good source of potassium, but not the best. According to the USDA, one cup of cooked spinach contains 839 mg of potassium, which is about 18% of the recommended daily intake (RDI) for adults².
Choice B reason: Baked potato is the best source of potassium among the choices. According to the USDA, one medium baked potato with skin contains 941 mg of potassium, which is about 20% of the RDI for adults². Potassium is an essential mineral that helps regulate fluid balance, nerve and muscle function, and blood pressure.
Choice C reason: Banana is a popular source of potassium, but not the best. According to the USDA, one medium banana contains 422 mg of potassium, which is about 9% of the RDI for adults².
Choice D reason: Cheese is a poor source of potassium. According to the USDA, one ounce of cheddar cheese contains only 28 mg of potassium, which is less than 1% of the RDI for adults². Cheese is high in sodium, which can counteract the benefits of potassium and increase the risk of hypertension.
Correct Answer is A
Explanation
Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
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