A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Distended jugular veins.

Generalized urticaria.

Bilateral flank pain.

Blood pressure 184/92 mm Hg.

Answer and Explanation

The Correct Answer is B

A. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction.

B. Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin.

C. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction.

D. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.

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Correct Answer is ["B","E","F"]

Explanation

A. Bananas are not a significant source of vitamin B12.

B. Eggs are a good source of vitamin B12 and should be included in the diet of someone with a deficiency.

C. Spinach contains folate but is not a reliable source of vitamin B12.

D. Carrots are not a source of vitamin B12.

E. Beef is an excellent source of vitamin B12 and should be consumed to help correct the deficiency.

F. Milk is a good source of vitamin B12 and can help increase intake for clients with a deficiency.

G. Quinoa does not contain vitamin B12 and should not be relied upon for addressing this deficiency.

A. Ensure comfortable seating at eye level for the client and nurse. B. Provide seating for the client so that the client faces a strong light. C. Ensure that the distance between the client and nurse is at least 7 ft (2.1 meters). D. Place a chair for the client across from the nurse's desk. E. Set the room temperature at a comfortable level. F. Remove distracting objects from the interviewing area.

Correct Answer is ["A","E","F"]

Explanation

A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.

B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.

C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.

D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.

E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.

F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.

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A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? Select all that apply.

Correct Answer is ["B","E","F"]

Explanation

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select three options that apply.

Correct Answer is ["A","E","F"]

Explanation

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