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 A

Explanation

A. Avoid crowds - Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens.

B. Eat plenty of fresh fruits and vegetables - While generally healthy, fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Cooked or properly washed and peeled produce is safer.

C. Take temperature weekly - Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early.

D. Perform mild exercise, such as gardening - Gardening can expose individuals to soil-borne organisms that could lead to infections. Indoor exercises or those that don’t involve potential pathogen exposure are safer.

A. Pain medication administration B. Poor nutritional state C. wound infection D. Obesity E. Altered mental status

Correct Answer is ["B","C","D"]

Explanation

A. Pain medication administration: Pain medications, while necessary, do not directly increase the risk of dehiscence.

B. Poor nutritional state: Adequate nutrition is essential for wound healing. Malnutrition can weaken tissue strength and delay healing.

C. Wound infection: Infection can weaken the tissue at the wound site, increasing the risk of dehiscence.

D. Obesity: Excess body weight can put pressure on the wound, making it more likely to open.

E. Altered mental status: This does not directly increase the risk of wound dehiscence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor?

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.)

A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?