The nurse is caring for a client receiving their second unit of Packed Red Blood Cells for an initial hemoglobin. The client appears flushed and complains of itching and urticaria. After following protocol (stopping transfusion, running 0.9% normal saline) and notifying the health care provider, the nurse would prepare to administer:
epinephrine 1mg IV.
acetaminophen 650mg PD.
diphenhydramine 50mg IV.
furosemide 40mg PO.
The Correct Answer is C
A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.
B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).
C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.
D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid using an electric razor
This is not directly relevant to trigeminal neuralgia management. Although it may be important for clients to avoid stimulating the face in general, an electric razor is not a specific concern for trigeminal neuralgia.
B. Meats should be served hot
Hot foods should actually be avoided, as extreme temperatures can trigger trigeminal neuralgia pain. Therefore, this recommendation is incorrect.
C. Teeth should be brushed prior to each meal
This is a reasonable recommendation for maintaining oral hygiene, but it does not specifically address managing trigeminal neuralgia pain. It is not as effective as the correct measure for managing trigeminal neuralgia.
D. Chew food on the unaffected side
Clients with trigeminal neuralgia may experience severe pain on one side of the face, especially when chewing. To reduce pain, it is recommended to chew food on the unaffected side to avoid triggering pain.
Correct Answer is ["A","E"]
Explanation
A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.
B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.
C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.
D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.
E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.
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