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

Answer and Explanation

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.

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Correct Answer is B

Explanation

The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.

The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.

A. "I can drink vegetable juice with a meal." B. "I can season my foods with garlic and onion salts." C. "I can have a frozen fruit juice bar for dessert." D. "I can have mayonnaise on my sandwiches."

Correct Answer is C

Explanation

A frozen fruit juice bar for dessert is a low-sodium option that can satisfy the client's sweet tooth. According to the National Health and Nutrition Examination Survey, Americans consume about 3700 mg of sodium daily, which is much higher than the recommended 2300 mg for the general population and 1500 mg for those with heart failure. Excessive sodium intake can lead to fluid retention, hypertension, and worsening of heart failure symptoms. Therefore, the client should avoid high-sodium foods such as vegetable juice, garlic and onion salts, and mayonnaise.

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A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

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