The nurse is staying with a patient who has been started on a blood transfusion. Which assessment should the nurse perform during a blood product infusion to detect a reaction?
a. Vital signs
b. Skin turgor
c. Bowel sounds
d. Pupil reactivity
ANS: A
Changes in vital signs can signal onset of transfusion reaction. B. C. D. Bowel sounds, pupils, and skin turgor are not generally affected with a transfusion reaction.
You might also like to view...
After breakfast, the patient with a history of chronic angina takes a shower and shaves. He then experiences angina. What might the nurse counsel the person to do to decrease the likelihood of angina in the morning?
A) Shower in the evening and shave before breakfast. B) Skip breakfast and eat an early lunch. C) Take a nitro tab prior to breakfast. D) Shower once a week and shave prior to breakfast.
The nurse is preparing to administer medication to a school-age client who weighs 66 lbs. The provider prescribes Kantrex (kanamycin). The medication is prescribed as 15 mg/kg/day, IM in equally divided doses every 12 hours
How many mg will the provider prescribe for this client? Round answer to the nearest whole number.
A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is most appropriate?
a. Insert an IV line and infuse fluids. b. Promote oral intake to 3000 mL/day. c. Provide a quiet, well-lit environment. d. Administer opioids to provide sedation.
New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant?
1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily.