Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is monitoring a client who is receiving 2 units of packed RBCs.
Which of the following manifestations indicates a hemolytic transfusion reaction?
A. Back pain.
Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
B. Bradycardia.
Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
C. Hypertension.
Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
D. Chills.
Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
Similar Questions
A nurse finds a client in bed, unresponsive and breathing.
Which of the following actions should the nurse take first?
A. Initiate cardiac monitoring for the client.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
B. Apply a blood pressure cuff.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
C. Palpate for the client's carotid pulse.
The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths. When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe. Tilting their head back opens the airway by pulling the tongue forward. Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
D. Establish an IV access.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.
Full Explanation
The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.
A nurse in a provider's office is teaching a client about the self-management of GERD.
Which of the following instructions should the nurse include?
A. "Increase your caloric intake by 250 calories per day."
Choice A: “Increase your caloric intake by 250 calories per day” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
B. "Lie down for 30 minutes after each meal."
Choice B: “Lie down for 30 minutes after each meal” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
C. "Eat a light meal 1 hour before bedtime."
Choice C: “Eat a light meal 1 hour before bedtime” is not an answer because it is not mentioned
D. "Sleep with the head of your bed elevated 6 inches.".
One of the lifestyle changes that doctors recommend for managing symptoms of gastroesophageal reflux disease (GERD) is elevating the head during sleep by placing a foam wedge or extra pillows under the head and upper back to incline the body and raising the head off the bed 6 to 8 inches.
Full Explanation
One of the lifestyle changes that doctors recommend for managing symptoms of gastroesophageal reflux disease (GERD) is elevating the head during sleep by placing a foam wedge or extra pillows under the head and upper back to incline the body and raising the head off the bed 6 to 8 inches.
Choice A: “Increase your caloric intake by 250 calories per day” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
Choice B: “Lie down for 30 minutes after each meal” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
Choice C: “Eat a light meal 1 hour before bedtime” is not an answer because it is not mentioned
A nurse in an emergency department is reviewing a client's ECG reading.
Which of the following findings should the nurse identify as an indication that the client has first-degree heart block?
A. Prolonged PR intervals.
First-degree heart block is a type of atrioventricular (AV) block that involves the consistent prolongation of the PR interval (defined as >0.20 seconds) due to delayed conduction via the atrioventricular node. This is seen on an ECG as a PR interval greater than 200 ms in length.
B. Nondiscernible P waves.
Choice B: Nondiscernible P waves are not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
C. More P waves than QRS complexes.
Choice C: More P waves than QRS complexes is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
D. No correlation between P and QRS waves.
Choice D: No correlation between P and QRS waves is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Full Explanation
First-degree heart block is a type of atrioventricular (AV) block that involves the consistent prolongation of the PR interval (defined as >0.20 seconds) due to delayed conduction via the atrioventricular node.
This is seen on an ECG as a PR interval greater than 200 ms in length.
Choice B: Nondiscernible P waves are not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Choice C: More P waves than QRS complexes is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Choice D: No correlation between P and QRS waves is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.