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 {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
The nurse should first review the medications that may be causing the client's confusion, as certain drugs can contribute to altered mental status and should be promptly identified and addressed. After identifying and managing the cause, the nurse should focus on using alternative methods to keep the client safe, ensuring both immediate and long-term patient safety, especially if medication adjustments are required.
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.
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