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
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.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. "HIPAA is a federal law, not a state law": This statement is correct. HIPAA is indeed a federal law that sets standards for the protection of health information.
B. "A client's address would be an example of personally identifiable information": This statement is correct. A client's address is considered personally identifiable information under HIPAA.
C. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form": This statement is correct. HIPAA regulates the privacy and security of health information in all forms.
D. "Information about a client can be disclosed to family members at any time": This statement indicates a need for further teaching. HIPAA restricts the disclosure of client information and requires consent or authorization before disclosing information to family members, unless there is a specific exception such as in emergency situations or where the client has consented.
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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