The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

The transfusion will begin after the administration of 650 mg of acetaminophen {Tylenol).

The blood will be held, and the health care provider will be notified

The transfusion will begin after the administration of an antihistamine

The transfusion will begin as prescribed

Answer and Explanation

The Correct Answer is A

A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).

This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.

B. The blood will be held, and the health care provider will be notified.

This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.

C. The transfusion will begin after the administration of an antihistamine.

Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.

D. The transfusion will begin as prescribed.

This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. “Call your surgeon if you have any questions at home.”

This instruction is important as it encourages the patient to seek help and clarification if they have any concerns or questions about their postoperative care at home. However, while communication with the surgeon is essential, it is not as immediately critical as ensuring proper hand hygiene when dealing with wound care and drain management.

B. ”Eat a diet high in protein, iron, zinc, and vitamin C.”

Nutritional advice is crucial for postoperative recovery, as a balanced diet high in protein, iron, zinc, and vitamin C can promote wound healing and overall recovery. However, while important for long-term recovery and healing, dietary recommendations do not directly address the immediate risk of infection or complications associated with wound care and drain management.

C. “Wash your hands before touching the drain or dressing."

This instruction is the most important in this context because proper hand hygiene is crucial for preventing infections during wound care and drain management. Clean hands significantly reduce the risk of introducing harmful bacteria or contaminants to the surgical site, which can lead to infections and other complications. Ensuring that the patient washes their hands before touching the drain or dressing is a fundamental measure for promoting wound healing and preventing postoperative complications.

D. “Be sure you keep all your postoperative appointments.”

Keeping postoperative appointments is important for ongoing assessment, monitoring, and follow-up care. However, while essential for overall recovery and management of postoperative issues, it is not as immediate or directly related to the patient's ability to manage their dressing and drain at home.

A. A 60 year old client with gastritis B. A 20 year old client with closed tibia fracture C. A 55 year old client taking an ACE inhibitor D. A 35 year old client receiving chemotherapy

Correct Answer is D

Explanation

A. A 60-year-old client with gastritis:

Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.

B. A 20-year-old client with a closed tibia fracture:

A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.

C. A 55-year-old client taking an ACE inhibitor:

ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.

D. A 35-year-old client receiving chemotherapy:

Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Correct Answer is C

Explanation

A nurse is caring for several clients. Which of the following clients is most prone to skin infections?

Correct Answer is D

Explanation

A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)

A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

The nurse debriding a burn wound explains that the purpose of debridement is to:

A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

A nurse is caring for a 70-year-old client who has a pressure injury in the coccyx area. The nurse identifies that which of the following factors associated with aging may impact the ability for the ulcer to heat?

A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen?

A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?