For which client receiving a blood transfusion should the nurse remain especially alert for the possible development of transfusion-associated graft-versus-host disease (TA-GVHD)?
A. 27-year-old pregnant woman with sickle cell anemia
B. 45-year-old man on immunosuppressant therapy after a kidney transplant
C. 68-year-old man receiving an autologous transfusion after hip replacement surgery
D. 56-year-old woman who is AB-positive receiving a transfusion with O-negative blood products
B
Transfusion-associated graft-versus-host disease is rare but most likely to occur either in immu-nosuppressed transfusion recipients or immunocompetent recipients receiving blood donated by first-degree relatives.
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a. 10 b. 16 c. 21 d. 29
Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first?
1. Place the client in McRoberts position. 2. Watch for the emergence of the placenta. 3. Prepare for the delivery of an undiagnosed twin. 4. Place the client in a supine position.
Which laboratory finding does the nurse report to the prescriber before giving any antihyperlipi-demic drug?
a. Aspartate aminotransferase 41 IU/L b. Alanine aminotransferase 24 IU/L c. Alkaline phosphatase 130 IU/L d. Gamma-glutamyltransferase 50 IU/L
The nurse is caring for a patient 6 hours after a thyroidectomy and notes the patient's temperature is 104°F, pulse is 144 beats per minute, respirations are 24 per minute, and blood pressure is 184/108 mm Hg
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