A nurse is monitoring a patient who is receiving a blood transfusion.
Which of the following symptoms should the nurse report to the charge nurse as a sign of an allergic blood transfusion reaction?
Bilateral flank pain.
Distended jugular veins.
Generalized urticaria.
Blood pressure 184/92 mm Hg.
The Correct Answer is C
Choice A rationale:
Bilateral flank pain is not a typical sign of an allergic blood transfusion reaction. It can be associated with other conditions, such as kidney problems, musculoskeletal issues, or abdominal aortic aneurysm. While it's important to assess flank pain, it doesn't directly suggest an allergic reaction to the transfusion.
Choice B Rationale:
Distended jugular veins can indicate fluid overload, which could potentially occur during a transfusion. However, it's not a specific sign of an allergic reaction. Fluid overload can result from various causes, including heart failure, kidney problems, or excessive fluid intake. It's crucial to monitor for fluid overload during transfusions, but it doesn't definitively point to an allergic reaction.
Choice C Rationale:
Generalized urticaria, or hives, is a hallmark sign of an allergic reaction. It's characterized by raised, red, itchy welts that can appear on various parts of the body. Hives can develop rapidly and spread extensively. During a blood transfusion, generalized urticaria strongly suggests that the patient's immune system is reacting to a component of the transfused blood, such as proteins or antibodies.
Choice D Rationale:
Blood pressure 184/92 mm Hg is elevated and could be concerning, but it's not specific to allergic reactions. High blood pressure can have various causes, including stress, pain, anxiety, or underlying hypertension. While monitoring blood pressure during transfusions is essential, it doesn't directly indicate an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Confidentiality: Patient information stored within the facility's computer system is highly confidential and protected by various laws and regulations, such as HIPAA (Health Insurance Portability and Accountability Act). Sharing a password with anyone, even trusted colleagues, could potentially compromise patient privacy and lead to unauthorized access or breaches of sensitive data. Nurses are ethically and legally obligated to safeguard patient confidentiality and uphold the highest standards of privacy protection.
Accountability: Each nurse is held individually accountable for any actions taken under their unique login credentials. Sharing a password blurs the lines of responsibility and makes it difficult to trace actions back to the specific individual who performed them. This can create accountability issues and impede investigations in cases of errors, misconduct, or security breaches.
Security Best Practices: Password sharing is universally discouraged by cybersecurity experts as it significantly weakens system security. Strong passwords, kept confidential and changed regularly, are essential for protecting sensitive information from unauthorized access, malware, and potential cyberattacks.
Facility Policies: Most healthcare facilities have strict policies prohibiting password sharing to maintain compliance with regulations and safeguard patient privacy. Violating these policies could lead to disciplinary action, including termination of employment.
Choice B rationale:
While a nurse manager may have a legitimate need to access patient information in certain situations, sharing a password is not the appropriate method for granting such access. Facilities typically have designated procedures for authorized individuals to obtain temporary or secondary login credentials, ensuring accountability and adherence to security protocols.
Choice C rationale:
Unit clerks, while often responsible for administrative tasks within a unit, do not have a clinical role that necessitates access to patient information through the nurse's password. Sharing a password with a unit clerk could lead to unauthorized access and potential privacy violations.
Choice D rationale:
The facility's information system representative is responsible for maintaining the technical infrastructure of the computer system, but they do not require access to patient information through individual nurse passwords. They have their own authorized means of accessing the system for troubleshooting and maintenance purposes.
Correct Answer is B
Explanation
Choice A rationale:
The spinal cord plays a crucial role in pain transmission, but it does not initiate the afferent pathways. It receives pain signals from nociceptors and relays them to the brain for processing.
The spinal cord is also involved in pain modulation, as it can dampen or amplify pain signals depending on various factors. However, it is not the primary trigger for pain sensation. That role belongs to nociceptors.
Choice B rationale:
Nociceptors are specialized sensory receptors that detect potentially damaging stimuli, such as intense heat, pressure, or chemical irritants.
They are located throughout the body, including the skin, muscles, joints, and internal organs.
When nociceptors are activated, they generate electrical signals that travel along nerve fibers to the spinal cord and brain. This process initiates the afferent pathways, which ultimately lead to the conscious perception of pain.
Nociceptors are essential for protecting the body from harm. They alert us to potential dangers and trigger responses that help us avoid injury or further damage.
Choice C rationale:
Endorphins are natural pain-relieving substances produced by the body. They act on receptors in the brain and spinal cord to reduce pain perception.
However, endorphins do not trigger the afferent pathways. They work by modulating pain signals that have already been initiated by nociceptors.
Choice D rationale:
The cortex is the outer layer of the brain that is responsible for higher-level functions, such as thinking, feeling, and decision- making.
It plays a role in the conscious experience of pain, but it does not trigger the afferent pathways.
The cortex receives pain signals from the spinal cord and processes them, leading to the awareness of pain.
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