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 B
No explanation
Correct Answer is A
Explanation
The correct answer is choice A. Washing hands after leaving the room is an important infection control measure for individuals who come into contact with clients on contact precautions. Choice B is incorrect because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is incorrect because gloves should not be reused. Choice D is incorrect because the client should not leave the room while on contact precautions. Choice B is not correct because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is not correct because gloves should not be reused. Choice D is not correct because the client should not leave the room while on contact precautions.
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