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. Bone pain: Bone pain is not a characteristic finding of hypomagnesemia. Hypomagnesemia is an electrolyte imbalance, and bone pain is not a typical symptom associated with it.
B. Drowsiness: Drowsiness may occur in hypomagnesemia, but it is not a specific or characteristic sign of this condition. Other electrolyte imbalances and medical conditions can also cause drowsiness.
C. Bowel hypomotility: Hypomagnesemia can cause bowel hypomotility (decreased bowel movements), but it is not the most specific finding associated with this condition.
D. Positive Chvostek's sign: Correct. Hypomagnesemia can lead to neuromuscular irritability, and a positive Chvostek's sign is a clinical manifestation of this condition. A positive Chvostek's sign is elicited by tapping the facial nerve (at the level of the zygomatic arch) and observing a
twitching of the facial muscles, which indicates increased neuromuscular excitability.
Correct Answer is D
Explanation
A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.
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