A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Anaphylactic

Acute hemolytic

Febrile

Circulatory overload

Answer and Explanation

The Correct Answer is A

A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.

B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.

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Correct Answer is C

Explanation

A. Tachypnea: Tachypnea (rapid breathing) is not a typical effect of magnesium sulfate. Magnesium sulfate is more likely to cause respiratory depression, especially at higher doses, rather than increasing the rate of breathing.

B. Tachycardia: Tachycardia (rapid heart rate). is not a common finding with magnesium sulfate administration. Magnesium sulfate typically causes a decrease in heart rate (bradycardia. and may also contribute to hypotension.

C. Hypotension: Hypotension is the correct finding. Magnesium sulfate has a vasodilatory effect, which can lead to a drop in blood pressure. This is a well-known side effect of magnesium sulfate, particularly when administered intravenously.

D. Hyperthermia: Hyperthermia (elevated body temperature). is not a typical finding associated with magnesium sulfate. Instead, magnesium sulfate can sometimes cause mild flushing, but it does not generally lead to an increase in body temperature.

A. Store the dentures in a dry denture cup on the bedside table after cleaning. B. Place a towel in the sink when cleaning the dentures. C. Remove the lower dentures before the upper dentures. D. Use a circular motion to cleanse the biting surface of the dentures.

Correct Answer is B

Explanation

A. Store the dentures in a dry denture cup on the bedside table after cleaning.: Dentures should not be stored in a dry cup as this can lead to drying out and warping of the dentures. They should be stored in water or a denture solution to keep them moist.

B. Place a towel in the sink when cleaning the dentures.: This is correct. Placing a towel in the sink is a safety precaution to prevent dentures from breaking if they are accidentally dropped while being cleaned. It also helps prevent damage from impact with hard surfaces.

C. Remove the lower dentures before the upper dentures.: There is no specific order required for removing dentures, as both upper and lower dentures should be removed carefully and cleaned.

D. Use a circular motion to cleanse the biting surface of the dentures.: A circular motion is not the best technique for cleaning dentures. Instead, the dentures should be brushed gently with a soft toothbrush, focusing on cleaning all surfaces, including the biting surfaces, using a back-and-forth motion.

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A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

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