A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?
Dyspnea
Fever
Pruritus
Bradycardia
The Correct Answer is A
Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.
An explanation for incorrect choices:
B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.
C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.
D. Bradycardia is not typically associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.
Correct Answer is D
Explanation
Choice A rationale: Applying an estrogen vaginal cream daily is not a risk factor for osteoporosis. In fact, estrogen can help maintain bone density.
Choice B rationale: Including canned sardines in the diet provides calcium and vitamin D, which are beneficial for bone health.
Choice C rationale: Walking 30 minutes per day is a weight-bearing exercise that helps maintain bone density and is beneficial for preventing osteoporosis.
Choice D rationale: Using a beclomethasone inhaler (a corticosteroid) can be a risk factor for osteoporosis, especially if used long-term, as corticosteroids can lead to bone loss.
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