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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Performing sponge baths until the baby's umbilical cord falls off is a recommended practice to prevent infection and promote healing of the cord stump. The bath water should be warm but not hot, around 85 to 90 degrees Fahrenheit. Talcum powder can irritate the baby's skin and lungs and should be avoided. Alkaline soap can dry out the baby's skin and should be replaced with a mild, pH-balanced cleanser.
Correct Answer is C
Explanation
The correct answer is C. Place a pillow under the child's head.
Rationale: The nurse should protect the child from injury by helping them to the floor and clearing away furniture or other items. The nurse should also place a pillow under the child's head to prevent head trauma and turn them onto their side to prevent aspiration of saliva or vomit. The nurse should not put anything in the child's mouth, as this could cause choking or damage to the teeth or tongue. The nurse should also not turn the child onto their back, as this could compromise their airway. The nurse should not restrain the child's upper extremities, as this could increase muscle spasms and cause injury.
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