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?

Febrile

Circulatory overload

Acute hemolytic

Anaphylactic

Answer and Explanation

The Correct Answer is D

The correct answer is D. Anaphylactic reactions are characterized by urticaria, wheezing, hypotension, and bronchospasm. They are caused by an IgE-mediated hypersensitivity to plasma proteins in the donor blood.

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Correct Answer is B

Explanation

The correct answer is B. The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.

A. Cleanse the inner cannula with isopropyl alcohol B. Prepare sterile supplies after removing the inner cannula. C. Clean the stoma using an inward to outward circular motion D. Ensure at least three finger widths of space under tracheostomy ties.

Correct Answer is C

Explanation

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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