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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Pull the auricle down and out: For a child under 3 years old, the ear canal is more horizontal, so the auricle should be pulled down and out to straighten the ear canal for proper instillation of ear drops.

B. Pull the auricle up and back: This technique is used for children older than 3 years old, as their ear canal becomes more vertical.

C. Pull the auricle up and out: This technique is incorrect for a 3-year-old child as it does not account for the horizontal position of the ear canal in younger children.

D. Pull the auricle down and back: This technique is not recommended for ear drops in young children and does not align with the anatomical considerations for their ear canal.

A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side. B. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion. 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. 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.

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.

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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 preparing to instill ear drops to a 3-year-old child. Which of the following techniques should the nurse use?

Correct Answer is A

Explanation

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

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