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 A

Explanation

Choice A reason: Metabolic alkalosis is a condition in which the blood pH is elevated due to an excess of bicarbonate or a loss of acid. It can be caused by nausea and vomiting, as they result in the loss of gastric acid and the retention of bicarbonate.

Choice B reason: Respiratory acidosis is a condition in which the blood pH is lowered due to an accumulation of carbon dioxide. It can be caused by hypoventilation, airway obstruction, or lung diseases. It is not related to nausea and vomiting.

Choice C reason: Metabolic acidosis is a condition in which the blood pH is lowered due to an excess of acid or a loss of bicarbonate. It can be caused by diabetic ketoacidosis, renal failure, or lactic acidosis. It is not caused by nausea and vomiting.

Choice D reason: Respiratory alkalosis is a condition in which the blood pH is elevated due to a loss
carbon dioxide. It can be caused by hyperventilation, anxiety, fever, or aspirin overdose. It is not common in clients who have nausea and vomiting.

A. Every 2 hr while the client is awake B. When the client has the urge to defecate C. Immediately before meals D. After the client feels abdominal cramping

Correct Answer is B

Explanation

Choice A: Taking the client to the bathroom every 2 hours while awake is not an effective strategy for bowel training. This may disrupt the client's natural bowel rhythm and cause unnecessary stress and frustration. Bowel training aims to establish a regular and predictable time for elimination, not a frequent and arbitrary one¹².
Choice B: Taking the client to the bathroom when they have the urge to defecate is the best option for bowel training. This helps the client to respond to their body's signals and avoid suppressing or delaying the urge. It also reinforces the association between the urge and the act of defecation, which can improve bowel control and prevent constipation¹².
Choice C: Taking the client to the bathroom immediately before meals is not a good idea for bowel training. This may interfere with the client's appetite and digestion, as well as their social and emotional well-being. Bowel training should not be associated with negative or unpleasant feelings. Moreover, eating stimulates the gastrocolic reflex, which increases the motility of the colon and the likelihood of having a bowel movement after a meal¹³.
Choice D: Taking the client to the bathroom after they feel abdominal cramping is not a reliable method for bowel training. Abdominal cramping may indicate various conditions, such as irritable bowel syndrome, food intolerance, infection, or inflammation. It may not always be related to the need to defecate. Waiting for cramping to occur may also delay the evacuation and worsen the symptoms¹³.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

Correct Answer is A

Explanation

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

Correct Answer is B

Explanation

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