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 C

Explanation

The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.

Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of

the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.

A. Cover the wound with sterile, saline-soaked gauze. B. Raise the head of the bed to a 45° angle. C. Hold gentle, direct pressure on the protruding organ D. Place the client's knees in an extended position.

Correct Answer is A

Explanation

Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.

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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 preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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