The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

“I probably will not have any transfusion reactions from my own blood."

“This is the blood I've been giving for the past 6 weeks for myself.

"I understand there is still a risk I can get hepatitis from this blood."

"Since I have O negative blood, it's a good thing I'm getting my own blood."

Answer and Explanation

The Correct Answer is C

A.   “I probably will not have any transfusion reactions from my own blood.” - Autologous transfusions
generally have a lower risk of transfusion reactions because they involve the client’s own blood.
B.   “This is the blood I’ve been giving for the past 6 weeks for myself.” - This is a correct understanding of the process of autologous blood donation, where the client donates blood for their own use.
C.   An autologous blood transfusion involves the collection and storage of a patient's own blood for later transfusion. This significantly reduces the risk of bloodborne infections, such as hepatitis, HIV, and other blood-borne diseases, as the blood is coming from the patient themselves.
D.   “Since I have O negative blood, it’s a good thing I’m getting my own blood.” - The client may not need additional teaching here because O negative blood is universally compatible, but the reason they are getting their own blood is due to the autologous donation process, not because of blood type.

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Correct Answer is D

Explanation

A. The 12-lead EKG might be unnecessary right now, especially since the client has no other alarming symptoms. Bumetanide is also not indicated for nausea or tachycardia in this scenario.
B. There is no clear indication that the nausea is related to acid reflux or GI distress that would justify pantoprazole.
C. The tachycardia could be physiological, and treating it with a beta-blocker is unnecessary unless there is a more concerning underlying cause (like heart failure or ischemia). The priority here is not pharmacological intervention but monitoring the client's overall condition.
D. This action allows for appropriate monitoring of the client's condition. Sinus tachycardia may resolve on its own without intervention, and the client doesn't exhibit severe symptoms requiring immediate pharmacologic treatment.

A. The pacemaker is pacing abnormally B. Biventricular, pacing in both ventricles C. Atrial paced rhythm D. Atrial and ventricular pacing

Correct Answer is D

Explanation

A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

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The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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