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

Choice A reason:

Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.

Choice B reason:

Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.

Choice C reason:

Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.

Choice D reason:

Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity.

A. Provide frequent reorientation after ECT. B. Schedule follow-up ECT treatments 1 month apart. C. Instruct the client to notify the provider if discomfort is felt during ECT. D. Initiate NPO status 1 hr prior to ECT.

Correct Answer is A

Explanation

The correct answer is A.

Provide frequent reorientation after ECT. The rationale is that ECT can cause temporary memory loss and confusion, which can be distressing for the client. The nurse should help the client recall their name, location, date, and reason for ECT. The nurse should also reassure the client that their memory will improve over time.

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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 assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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