A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Hemolysis

Urticaria

Fever

Fluid overload

Answer and Explanation

The Correct Answer is B

A. Hemolysis: This is a severe reaction to blood transfusion involving the destruction of red blood cells and requires different management strategies.

B. Urticaria: Diphenhydramine is used to prevent or treat urticaria (hives), which is a mild allergic reaction and can be managed with antihistamines.

C. Fever: This is typically managed with antipyretics or by addressing the underlying cause rather than antihistamines.

D. Fluid overload: This condition requires management with diuretics and careful monitoring of fluid intake rather than antihistamines.

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Correct Answer is D

Explanation

A. A client who is being discharged to a long-term care facility: This may involve extensive discharge teaching and planning, which may not align with the float nurse’s PACU experience.

B. A client who needs teaching prior to initiating cardiac rehabilitation activities: This requires specialized knowledge in cardiac rehabilitation and patient education.

C. A client who needs teaching about insulin self-administration: This requires specific knowledge about diabetes management and patient education.

D. A client who is postoperative following a lobectomy and has a chest tube: The float nurse from the PACU is likely familiar with postoperative care and management of chest tubes, making this client the most suitable for their expertise.

A. The client waits 10 min between inhalations. B. The client holds his breath for 10 seconds after inhaling the medication. C. The client takes a quick inhalation while releasing the medication from the inhaler. D. The client exhales as the medication is released from the inhaler.

Correct Answer is B

Explanation

A. The client waits 10 min between inhalations: Waiting 10 minutes between inhalations is unnecessary for a rescue inhaler like albuterol. Typically, it is sufficient to wait for 1 to 2 minutes if more doses are required.

B. The client holds his breath for 10 seconds after inhaling the medication: This is correct. Holding the breath for about 10 seconds after inhalation allows the medication to settle in the airways and enhances its effectiveness.

C. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. A slow, deep inhalation is recommended to ensure that the medication reaches the lower airways.

D. The client exhales as the medication is released from the inhaler: This is incorrect. The client should exhale fully before inhaling the medication to ensure that the medication can be inhaled deeply into the lungs.

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A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

Correct Answer is D

Explanation

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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