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 C

Explanation

A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side: The direction of the snap is not as critical as ensuring the use of proper technique to avoid injury and contamination.

B. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion: Breaking the ampule downward could risk contamination and injury if not done properly.

C. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body: This method minimizes the risk of glass shards and helps to prevent injury and contamination, ensuring safe handling of the medication.

D. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body: Breaking the ampule toward the body is unsafe and increases the risk of injury from glass shards.

A. Administer pain medication to the first client. B. Weigh the second client. C. Change the dressings of both clients. D. Obtain vital signs for both clients.

Correct Answer is A

Explanation

A. Administer pain medication to the first client: Pain management is a priority, especially for a postoperative patient with a pain level of 6 out of 10. Addressing pain can improve the client’s comfort and ability to participate in other aspects of care, such as nutrition administration and mobility.

B. Weigh the second client: While important for monitoring nutritional status, weighing the client is not as urgent as managing pain for a postoperative patient.

C. Change the dressings of both clients: Dressing changes are necessary but can be scheduled after addressing the more immediate needs such as pain management for the postoperative client.

D. Obtain vital signs for both clients: While vital signs are important for assessing overall health, pain management should be prioritized to address the immediate discomfort and potential impacts on recovery.

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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 is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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