The nurse is assisting with the care of a client who is receiving a unit of packed RBCs.
Complete the following sentence by using the lists of options. Exhibit 1
The client has manifestations of an
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administer
medications.
B. Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy.
C. Identify the client by comparing the medication administration record with the client's room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due.
D. Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the "three checks" and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.
Correct Answer is B
Explanation
A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
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