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NurseDive Free Nursing Practice Question
A nurse is collecting data on a client who is receiving a unit of PRBCs. Which of the following findings is a manifestation of an allergic transfusion reaction?
A. Flank pain
Flank pain is not a sign of an allergic transfusion reaction. Flank pain is a pain in the side of the abdomen or back, usually caused by kidney problems, such as infection, stones, or injury. Flank pain can be a sign of a hemolytic transfusion reaction, which is a serious complication that occurs when the donor blood is incompatible with the recipient's blood type.
B. Elevated blood pressure
Elevated blood pressure is not a sign of an allergic transfusion reaction. Elevated blood pressure is a condition where the force of the blood against the artery walls is too high, which can increase the risk of heart disease, stroke, and kidney damage. Elevated blood pressure can be a sign of a hypertensive transfusion reaction, which is a rare complication that occurs when the donor blood has a higher sodium level than the recipient's blood.
C. Distended neck veins
Distended neck veins are not a sign of an allergic transfusion reaction. Distended neck veins are a sign of increased pressure in the right side of the heart or the superior vena cava, which can be caused by heart failure, pulmonary hypertension, or obstruction. Distended neck veins can be a sign of a circulatory overload transfusion reaction, which is a complication that occurs when the blood volume or rate of infusion is too high for the recipient's cardiovascular system.
D. Wheezing
Wheezing is a sign of an allergic transfusion reaction. Wheezing is a high-pitched whistling sound that occurs when the airways are narrowed or inflamed, which can cause difficulty breathing, coughing, or chest tightness. Wheezing can be a sign of an allergic transfusion reaction, which is a hypersensitivity response to the donor blood or its components, such as plasma proteins, antibodies, or preservatives. An allergic transfusion reaction can range from mild to severe, and can be treated with antihistamines, corticosteroids, or epinephrine.
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: Flank pain is not a sign of an allergic transfusion reaction. Flank pain is a pain in the side of the abdomen or back, usually caused by kidney problems, such as infection, stones, or injury. Flank pain can be a sign of a hemolytic transfusion reaction, which is a serious complication that occurs when the donor blood is incompatible with the recipient's blood type.
Choice B reason: Elevated blood pressure is not a sign of an allergic transfusion reaction. Elevated blood pressure is a condition where the force of the blood against the artery walls is too high, which can increase the risk of heart disease, stroke, and kidney damage. Elevated blood pressure can be a sign of a hypertensive transfusion reaction, which is a rare complication that occurs when the donor blood has a higher sodium level than the recipient's blood.
Choice C reason: Distended neck veins are not a sign of an allergic transfusion reaction. Distended neck veins are a sign of increased pressure in the right side of the heart or the superior vena cava, which can be caused by heart failure, pulmonary hypertension, or obstruction. Distended neck veins can be a sign of a circulatory overload transfusion reaction, which is a complication that occurs when the blood volume or rate of infusion is too high for the recipient's cardiovascular system.
Choice D reason: Wheezing is a sign of an allergic transfusion reaction. Wheezing is a high-pitched whistling sound that occurs when the airways are narrowed or inflamed, which can cause difficulty breathing, coughing, or chest tightness. Wheezing can be a sign of an allergic transfusion reaction, which is a hypersensitivity response to the donor blood or its components, such as plasma proteins, antibodies, or preservatives. An allergic transfusion reaction can range from mild to severe, and can be treated with antihistamines, corticosteroids, or epinephrine.
Similar Questions
A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female client. Which of the following actions by the nurse should prompt the charge nurse to intervene?
A. The nurse applies the sterile drape prior to cleansing the perineal area.
The nurse applies the sterile drape prior to cleansing the perineal area. This is a correct action by the nurse, as it helps to prevent contamination of the catheter insertion site and maintain a sterile field.
B. The nurse coats the indwelling urinary catheter with lubricant.
The nurse coats the indwelling urinary catheter with lubricant. This is a correct action by the nurse, as it helps to ease the insertion of the catheter and reduce the risk of trauma or infection.
C. The nurse separates the client's labia with her dominant hand.
The nurse separates the client's labia with her dominant hand. This is an incorrect action by the nurse, as it violates the principle of sterile technique. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and use her dominant hand to hold the catheter. The non-dominant hand should not touch anything else after separating the labia, as it is considered contaminated.
D. The nurse provides perineal care prior to inserting the urinary catheter.
The nurse provides perineal care prior to inserting the urinary catheter. This is a correct action by the nurse, as it helps to reduce the bacterial load and prevent infection. The nurse should use soap and water to cleanse the perineal area from front to back, and use a new washcloth for each stroke.
Full Explanation
Choice A reason: The nurse applies the sterile drape prior to cleansing the perineal area. This is a correct action by the nurse, as it helps to prevent contamination of the catheter insertion site and maintain a sterile field.
Choice B reason: The nurse coats the indwelling urinary catheter with lubricant. This is a correct action by the nurse, as it helps to ease the insertion of the catheter and reduce the risk of trauma or infection.
Choice C reason: The nurse separates the client's labia with her dominant hand. This is an incorrect action by the nurse, as it violates the principle of sterile technique. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and use her dominant hand to hold the catheter. The non-dominant hand should not touch anything else after separating the labia, as it is considered contaminated.
Choice D reason: The nurse provides perineal care prior to inserting the urinary catheter. This is a correct action by the nurse, as it helps to reduce the bacterial load and prevent infection. The nurse should use soap and water to cleanse the perineal area from front to back, and use a new washcloth for each stroke.
A nurse is collecting data on a client who has circulatory overload. Which of the following findings should the nurse expect?
A. Tachycardia
Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.
B. Weight loss
Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.
C. Hypotension
Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.
D. Diaphoresis
Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.
Full Explanation
Choice A reason: Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.
Choice B reason: Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.
Choice C reason: Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.
Choice D reason: Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
A. Prone
Prone is not the best position to allow maximal lung expansion. Prone is a position where the client lies on their stomach, with their head turned to one side. Prone can help to improve oxygenation in some cases of acute respiratory distress syndrome (ARDS), but it can also increase the risk of pressure ulcers, facial edema, and airway obstruction.
B. Side-lying
Side-lying is not the best position to allow maximal lung expansion. Side-lying is a position where the client lies on their side, with their head supported by a pillow. Side-lying can help to prevent aspiration and reduce the work of breathing in some clients, but it can also compromise the ventilation of the dependent lung.
C. Supine
Supine is not the best position to allow maximal lung expansion. Supine is a position where the client lies on their back, with their head and shoulders slightly elevated. Supine can help to maintain a patent airway and facilitate suctioning in some clients, but it can also increase the risk of atelectasis, pneumonia, and hypoxemia.
D. Upright
Upright is the best position to allow maximal lung expansion. Upright is a position where the client sits or stands with their back straight and their chest expanded. Upright can help to improve lung compliance, reduce airway resistance, and enhance gas exchange in clients with respiratory failure. Upright can also reduce the pressure on the diaphragm and abdominal organs, and promote the drainage of secretions.
Full Explanation
Choice A reason: Prone is not the best position to allow maximal lung expansion. Prone is a position where the client lies on their stomach, with their head turned to one side. Prone can help to improve oxygenation in some cases of acute respiratory distress syndrome (ARDS), but it can also increase the risk of pressure ulcers, facial edema, and airway obstruction.
Choice B reason: Side-lying is not the best position to allow maximal lung expansion. Side-lying is a position where the client lies on their side, with their head supported by a pillow. Side-lying can help to prevent aspiration and reduce the work of breathing in some clients, but it can also compromise the ventilation of the dependent lung.
Choice C reason: Supine is not the best position to allow maximal lung expansion. Supine is a position where the client lies on their back, with their head and shoulders slightly elevated. Supine can help to maintain a patent airway and facilitate suctioning in some clients, but it can also increase the risk of atelectasis, pneumonia, and hypoxemia.
Choice D reason: Upright is the best position to allow maximal lung expansion. Upright is a position where the client sits or stands with their back straight and their chest expanded. Upright can help to improve lung compliance, reduce airway resistance, and enhance gas exchange in clients with respiratory failure. Upright can also reduce the pressure on the diaphragm and abdominal organs, and promote the drainage of secretions.