A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic. reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic

Allergic

Febrile

Bacterial

Answer and Explanation

The Correct Answer is A

A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.

B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.

C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.

D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.

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Correct Answer is B

Explanation

A. Consume foods high in potassium: Potassium is important for ear health, but there is no direct evidence that high-potassium foods alone reduce the risk of hearing loss.

B. Avoid smoking tobacco products: Smoking is associated with an increased risk of hearing loss due to its negative effects on blood flow to the cochlea and the auditory nerve. Avoiding smoking can reduce the risk of hearing damage.

C. Increase oral intake of water: While staying hydrated is good for overall health, it does not specifically impact hearing loss risk.

D. Limit alcohol to two drinks daily: Excessive alcohol consumption can affect hearing, but moderation is not directly associated with preventing hearing loss as effectively as avoiding smoking.

A. Massage over erythematous bony prominences. B. Implement a turning schedule every 4 hr. C. Keep the client's skin dry with powder. D. Minimize skin exposure to moisture. E. Use pillows to keep heels off the bed surface

Correct Answer is ["B","E"]

Explanation

A. Massage over erythematous bony prominences: Incorrect. Massaging over areas of erythema (redness) can cause further damage to the underlying tissues and should be avoided. It may exacerbate tissue injury and increase the risk of skin breakdown.

B. Use pillows to keep heels off the bed surface: Correct. Elevating the heels with pillows helps to reduce pressure and prevent pressure ulcers by keeping them off hard surfaces. This is a recommended practice to reduce the risk of heel pressure ulcers.

C. Implement turning schedule every 4 hr: Incorrect. A turning schedule of every 2 hours is generally recommended to prevent pressure ulcers. Four hours is too long and increases the risk of skin breakdown in immobile patients.

D. Keep the client's skin dry with powder: Incorrect. Powders can dry out the skin and increase friction, potentially leading to skin breakdown. It's more important to maintain moisture balance and avoid the use of powders on skin at risk.

E. Minimize skin exposure to moisture: Correct. Moisture can contribute to skin breakdown, especially in incontinent patients. It is crucial to keep the skin clean and dry to prevent moisture-associated skin damage.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing hearing loss. Which of the following risk factors should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is teaching a group of clients about causes for developing hearing loss, which of the following risk factors should the nurse include in the teaching?

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.]

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A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

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