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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Decreased plasma volume:Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.
B. Diuresis:Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.
C. Hypermagnesemia:Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.
D. Capillary leak:Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.
E. Loss of protein:Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.
Correct Answer is B
Explanation
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A. How many people live in your home?
This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.
B. Did you have a recent exposure to irritants?
This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.
C. Is nausea associated with your rash?
Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.
D. What is your body mass index?
Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.
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