A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?
Bradycardia
Hypertension
Chills
Back pain
The Correct Answer is D
Back pain is a common symptom of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks and destroys the donor's red blood cells. Other symptoms include fever, chills, dyspnea, chest pain, hypotension, tachycardia, hemoglobinuria, and jaundice. A hemolytic transfusion reaction is a medical emergency that requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Desmopressin is a synthetic form of antidiuretic hormone (ADH), which regulates water balance in the body. Diabetes insipidus is a condition caused by a deficiency or resistance to ADH, resulting in excessive urination and thirst. Desmopressin helps reduce urine output and prevent dehydration by mimicking the action of ADH on the kidneys. Lithium is a mood stabilizer that can cause nephrogenic diabetes insipidus by interfering with the response of the kidneys to ADH. Regular insulin is used to treat diabetes mellitus, not diabetes insipidus, as it lowers blood glucose levels by facilitating its uptake into cells.
Furosemide is a diuretic that increases urine output and can worsen dehydration in clients with diabetes insipidus.
Correct Answer is A
Explanation
The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.
The other actions are important but not as urgent as obtaining consent.
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